Meadowbrook At Chetek
Inspection history, citations, penalties and survey trends for this long-term care facility in Chetek, Wisconsin.
- Location
- 725 Knapp St, Chetek, Wisconsin 54728
- CMS Provider Number
- 525672
- Inspections on file
- 22
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Meadowbrook At Chetek during CMS and state inspections, most recent first.
The facility failed to prevent multiple significant medication errors when staff did not consistently verify medications against orders, left a med cart unattended, and did not remove discontinued drugs from circulation. A resident with orthostatic hypotension was given another resident’s Oxycontin ER and Amlodipine and required Narcan and hospitalization. Another resident with rib fractures received a discontinued opioid instead of the current pain medication. A hospice resident prescribed Lorazepam oral concentrate was repeatedly given tablet form and later received a dose after the drug was discontinued. Additional errors included a wrong Tacrolimus dose due to transcription error, a resident receiving another resident’s Atorvastatin, and a resident ingesting another resident’s gabapentin, clonidine, and Vitamin D after bedside medication cups were mixed up for two residents with the same initials.
A resident with orthostatic hypotension and a neurocognitive disorder received another resident’s medications, including Oxycontin ER and Amlodipine, from a licensed nurse, leading to administration of Narcan and hospital evaluation where the resident was found markedly orthostatic and required IV fluids and transfer to another hospital. Despite the facility’s abuse prevention policy defining possible neglect as failure to provide necessary goods or services to avoid harm, the DON reported that the incident was not reported to the state agency and the required 5-day investigation was not submitted on time, citing that it was the nurse’s first medication error and that there were no noted signs or symptom effects.
The facility failed to thoroughly investigate and promptly correct an initial opioid medication error, allowing additional serious medication errors to occur. A resident with rib fractures received a discontinued opioid that had not been removed from circulation. Subsequently, another cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER and Amlodipine, and required Narcan, ED care, and hospital transfer. A cognitively intact hospice resident with COPD, chronic pancreatitis, and anxiety, ordered Lorazepam oral concentrate, instead received the wrong dosage form (tablet) on multiple occasions and later received the medication again after it had been discontinued, as it was not removed from circulation. These errors occurred despite existing policy requiring verification of medication labels against orders and after management became aware of the first error but before all licensed nurses were educated.
Two residents were affected when the facility failed to follow its own policy for controlled substance destruction and discontinuation. For one resident, a discontinued Pregabalin (Lyrica) 50 mg order was not destroyed promptly and was documented as destroyed by only one nurse instead of two licensed staff. For another resident, Lorazepam ordered as an oral concentrate for terminal anxiety was logged as 0.5 mg tablets, and the controlled substance log showed doses being administered after the medication had been discontinued. The DON and ADON acknowledged awareness of these medication errors, while an RN described a destruction process involving a drug buster and two nurse signatures that was not followed in these instances.
Two residents did not receive medications in accordance with physician orders and labeling requirements. One hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder was ordered Lorazepam oral concentrate for terminal anxiety but was repeatedly given tablet doses instead, and the drug continued to be administered after it was discontinued. In a separate case, an RN was found using an unlabeled morphine oral solution bottle marked only with a handwritten number, later identified as belonging to a resident, and confirmed that this medication had been administered multiple times without proper labeling or resident identification.
The facility did not accurately report direct care staffing data to CMS via the PBJ system, resulting in underreported weekend staffing levels. Although management and HR staff stated that weekend staffing was consistent with weekdays, a review revealed that hours worked by staff who left employment before data was pulled were omitted from PBJ submissions. This led to the facility being flagged for low weekend staffing, potentially affecting all residents.
A resident with upper limb monoplegia and COPD, requiring assistance with mobility, was found unable to reach their call light, which was wrapped around a bedside rail. The resident reported that staff frequently left the call light out of reach after transfers, despite care plan instructions and facility policy requiring accessibility to minimize fall risk. The DON confirmed staff were aware of the resident's limitations and the need for the call light to be within reach.
A resident with multiple medical conditions and existing pressure injuries did not receive wound care as ordered by the physician. During observed care, an RN failed to perform hand hygiene, did not follow the prescribed wound care steps, and omitted the application of required treatments, resulting in a deficiency in both infection control and adherence to professional standards.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and high fall risk was left unsupervised in the bathroom, resulting in a fall, while another resident who vapes was not properly assessed or care planned for independent smoking, despite facility policy requiring such evaluation.
A resident requiring dialysis did not receive consistent pre- and post-dialysis assessments as required by facility policy and the care plan. Staff failed to document vital signs, weight, or inspection of the dialysis access site before or after dialysis treatments, and the DON confirmed that there was no established process for these assessments. The resident reported that vital signs were only sometimes checked after dialysis, and records showed only weekly documentation unrelated to dialysis sessions.
Staff failed to follow infection control protocols, including proper hand hygiene during wound and personal care, use of PPE for a resident with open wounds, and correct handling of a urinary catheter bag, which was repeatedly observed on the floor. These lapses involved multiple residents with complex medical needs and were not in accordance with facility policies.
The facility failed to follow its food storage and labeling policies, leading to multiple unlabeled and potentially expired food items in the walk-in refrigerator and resident kitchenette. The Dietary Manager and staff admitted to not labeling items with open dates, and expired items were found. The Nursing Home Administrator was unaware of any foodborne illnesses but acknowledged the deficiency after being informed by the Dietary Manager.
A facility failed to return a deceased resident's trust funds to the POA or family within 30 days, as required by policy. The resident's account showed a positive balance, but no conveyance was documented. A family member reported the facility refused to refund the balance, citing an outstanding debt. The NHA was unsure about the balance, and the Accounts Receivable Specialist claimed all accounts are usually settled within 30 days, highlighting a lapse in policy adherence.
Two residents experienced falls that were not immediately reported to the physician, violating the facility's policy. One resident with Alzheimer's disease fell and was not reported until a day later, while another resident with dementia had two unwitnessed falls, with no documentation of physician notification. The DON was unaware of the incidents until observing injuries.
Two residents in an LTC facility did not receive proper assessments following falls, as required by the facility's fall management policy. One resident, with severe cognitive impairment, was not thoroughly assessed after a fall, and the incident was not reported to hospice or family until the next day. Another resident, with dementia, experienced falls without documented assessments, and the DON was unaware of the incidents until observing facial bruising. These deficiencies highlight a failure in maintaining residents' well-being and communication protocols.
The facility failed to implement new fall interventions for three residents at risk for falls. One resident fell and had a planned intervention not added to their care plan. Another resident experienced two falls with no new interventions implemented. A third resident's care plan was not updated after a fall. The DON acknowledged the oversight.
The facility failed to ensure proper hand hygiene and use of hair nets in food service. A CNA entered the kitchen without a hair net, and a Dietary Cook handled food without changing gloves or using hand hygiene after touching unclean items. The Dietary Manager confirmed these practices were against facility policy.
A facility failed to follow physician orders to schedule a follow-up oncology appointment for a resident with a potentially metastatic lesion. The admission checklist process was not effectively executed, and the necessary information was not communicated to the Social Services Assistant responsible for scheduling. Staff interviews revealed confusion and a lack of timely action, resulting in the resident not receiving the required follow-up care.
The facility failed to evaluate hazards related to the use of an oscillating percussion vest for a resident with quadriplegia and high aspiration risk. The resident was observed alone during vest treatments, and staff did not consistently follow physician orders for post-treatment checks. The care plan lacked details on supervision during vest use, and no assessment was conducted to ensure the resident's safety while unsupervised.
A resident with epilepsy, cerebral palsy, and functional intestinal disorder received medication via G-tube without proper verification of tube placement. The LPN used an outdated method of injecting air and listening for noise, which is no longer the standard of practice. The facility's policy still included this outdated practice, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program. Staff did not perform proper hand hygiene during medication administration for a resident with severe cognitive impairment, and droplet precautions were removed prematurely for a COVID-19 positive resident due to a miscalculation of isolation days.
Multiple Significant Medication Errors and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite a policy requiring accurate, safe, and timely medication administration. The policy directs staff to verify medication labels against the medication sheet for accuracy of drug, frequency, duration, strength, and route, and to check physician orders if there is any discrepancy. In multiple instances, staff did not follow these procedures, resulting in residents receiving wrong medications, wrong doses, wrong dosage forms, and discontinued medications that had not been removed from circulation. One cognitively intact resident with orthostatic hypotension and neurocognitive disorder with Lewy bodies was given another resident’s medications after an RN left a medication cart unattended between two rooms and then returned and handed the wrong medications to the resident. The medications included Oxycontin ER 20 mg and Amlodipine 5 mg, and the resident subsequently required Narcan and hospitalization, with hospital records later documenting marked orthostatic blood pressure changes requiring IV electrolytes and hydration. Another resident admitted with multiple rib fractures had an order for Oxycodone 5 mg every 6 hours for pain that was discontinued and changed to Hydrocodone 5-325 mg; however, the discontinued Oxycodone was not removed from circulation, and the resident received the wrong opioid medication on a later date. A resident on hospice care with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of liquid on multiple dates. The Lorazepam was later discontinued but not removed from circulation, resulting in an additional dose being administered after discontinuation. Pharmacy review identified that another resident’s Tacrolimus dose was incorrectly transcribed in the medical record as 5 mg, two tablets twice daily instead of the ordered 0.5 mg, two tablets twice daily, and the resident received the wrong dose at morning administration. In separate incidents, one resident received another resident’s 40 mg Atorvastatin tablet, and another resident took another resident’s medications (gabapentin, clonidine, and Vitamin D) after medication cups were set at the bedside for two residents with the same initials, and one resident ingested the medications without checking the cup.
Failure to Timely Report Medication Error and Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report an incident of potential neglect to the state survey agency after a resident received the wrong medications, required Narcan, and was hospitalized. The facility’s abuse prevention policy defines possible neglect as the failure to provide goods or services necessary to avoid physical harm, pain, mental anguish, or emotional distress, or that could reasonably be expected to cause pain, injury, or death. The resident involved was admitted with orthostatic hypotension and a neurocognitive disorder with Lewy bodies, and had a BIMS score of 14/15, indicating intact cognition, with an activated power of attorney for health care. On the date of the incident, a licensed nurse administered medications intended for another resident, including Oxycontin ER 20 mg and Amlodipine 5 mg, to this resident. The physician was contacted immediately, Narcan was ordered and administered, and the resident was sent to the emergency department for observation of the medication error. In the hospital, the resident was found to be markedly orthostatic and received IV electrolytes and hydration, and was later transferred to another hospital when blood pressure began trending low, before eventually returning to the facility. During an interview with the surveyor, the DON stated the incident was not reported to the state agency because it was the nurse’s first medication error and there were no noted signs or symptom effects of receiving the wrong medication, and acknowledged that the 5-day investigation was not submitted within the required 5 days.
Failure to Investigate and Correct Medication Errors Leading to Multiple Significant Drug Administration Mistakes
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough and timely investigation and to implement corrective actions after an initial significant medication error, which allowed additional serious errors to occur. Facility policy on Medication Administration, revised 12/2025, requires accurate, safe, and timely administration of medications and verification of the medication label against the medication sheet, with physician orders checked if there is any discrepancy. Despite this, one resident admitted with multiple rib fractures was initially prescribed Oxycodone 5 mg every 6 hours for pain, which was discontinued and changed to Hydrocodone 5-325 mg every 6 hours on 06/26/25. On 07/02/25, this resident was administered the previously discontinued Oxycodone, which had not been removed from circulation. Following that event, the facility did not ensure that all licensed nurses were educated on medication administration requirements before their next shifts, and two further significant medication errors occurred. One cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER 20 mg and Amlodipine 5 mg, and required Narcan and transfer to the ED, where the resident was found to be markedly orthostatic and required IV electrolytes and hydration before transfer to another hospital when blood pressure trended low. Another cognitively intact hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder had been prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, which was discontinued on 06/19/25 but not removed from circulation. The controlled substance log showed that this resident repeatedly received the wrong dosage form (tablet instead of liquid) on multiple dates and again received the wrong form and a discontinued medication on 07/06/25. These events occurred while nurse management were aware of the initial error but had not yet ensured all licensed staff were educated prior to subsequent shifts.
Failure to Properly Destroy and Discontinue Controlled Substances
Penalty
Summary
The facility failed to ensure proper destruction and disposition of controlled substances for two residents, contrary to its policy requiring unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and with a witness to the destruction. For one resident, documentation showed an order for Pregabalin (Lyrica) 50 mg capsules twice daily that was later discontinued and changed to Pregabalin (Lyrica) 75 mg twice daily. The narcotic sheet for the 50 mg dose had an "X" across the sheet with a notation "Destroyed RN" and only one nurse’s signature. During interview, the DON stated that controlled substances should be discarded right away once it is known the resident will not be using them or when the provider discontinues the order, and acknowledged that the 50 mg Pregabalin should have been destroyed immediately and with two licensed staff, but was not. For another resident, Lorazepam oral concentrate 0.25 ml every four hours as needed for terminal anxiety was prescribed, but the facility’s controlled substance log initiated for this resident was labeled for Lorazepam 0.5 mg tablets. The log showed documentation that the resident continued to receive Lorazepam after the medication had been discontinued. In interviews, the DON and ADON acknowledged awareness of medication errors related to this situation. A registered nurse described the usual process for controlled substance destruction as using a drug buster in the medication storage room with two nurses signing off and verifying destruction, which contrasted with the documented practice in these cases.
Improper Labeling and Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled, stored, and administered according to physician orders and facility policy for two residents. One resident with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was admitted on 03/21/25 and placed on hospice care on 06/02/25. On that date, the resident was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of the ordered liquid concentrate. The controlled substance log initiated on 06/02/25 was labeled for Lorazepam 0.5 mg tablets, and documentation showed the resident received the wrong dosage form on multiple dates (06/04/25, 06/05/25, 06/06/25, 06/09/25, and 06/10/25). Additionally, the Lorazepam was discontinued on 06/19/25 but was not removed from circulation, and the resident received an additional dose without a physician’s order on 07/06/25. In a separate incident, a surveyor observed an RN at the medication cart and asked about narcotic administration. The RN presented the narcotic box, where the surveyor observed a morphine bottle with no label identifying the resident, the correct dose, or other required information, only a handwritten “#36” in permanent marker. When questioned, the RN had to search through narcotic records to determine that the bottle belonged to another resident and confirmed that the morphine oral concentration bottle was not properly labeled with the resident’s name, date of birth, pharmacy dispense date, or other identifying information. The RN acknowledged that this morphine had been administered 13 times without proper labeling and stated they had not realized the resident’s name was missing from the bottle. The DON later stated that liquid medications, especially morphine, were expected to be correctly labeled and that unlabeled morphine should not be administered.
Inaccurate PBJ Staffing Data Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. Despite facility staff, including the DON and HR, stating that weekend staffing levels were consistent with weekday staffing and that call-ins did not differ between weekends and weekdays, the PBJ data submitted for multiple fiscal quarters indicated excessively low weekend staffing. Upon review, it was discovered that the process used by Corporate HR to pull and enter staffing data into the PBJ system was flawed. Specifically, if a staff member left employment before the data was pulled, their name and corresponding hours worked were deleted from the report, resulting in underreporting of actual hours worked. This underreporting led to inaccurate PBJ submissions, which triggered the facility to be flagged for low weekend staffing. The deficiency was identified through interviews with facility leadership and review of submitted PBJ data, schedules, and staff postings, which confirmed that multiple staff hours worked on weekends were not reported. This issue had the potential to affect all 71 residents residing in the facility, as the reported staffing levels did not accurately reflect the care provided.
Failure to Ensure Call Light Accessibility for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with monoplegia of the upper limb and COPD was not provided reasonable accommodation for their needs, specifically regarding access to their call light. The resident's care plan required that the call light be kept within reach due to their risk for falls and limited mobility. However, during an observation, the resident was found sitting in a wheelchair with the call light wrapped around the far-left bedside rail, out of reach. The resident was heard yelling for help and reported that staff often forgot to place the call light within reach after transfers from bed to wheelchair. The resident's most recent assessment indicated intact cognition and a need for partial to moderate assistance with mobility. The facility's fall management policy required adequate supervision and assistive devices to minimize fall risk. Despite this, staff failed to ensure the call light was accessible, as confirmed by both the resident and the DON, who acknowledged staff awareness of the resident's limitations and the importance of call light accessibility.
Failure to Follow Wound Care Orders and Infection Control During Pressure Injury Treatment
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, end stage renal disease, diabetes mellitus type 2, peripheral vascular disease, and chronic venous insufficiency, was admitted to the facility with several pressure injuries (PIs) and diabetic foot ulcers. The resident was dependent on staff for most activities of daily living and was identified as being at risk for pressure injuries. Physician orders specified a detailed wound care regimen, including cleansing, application of skin prep, Santyl ointment, calcium alginate, and zinc oxide to specific areas, to be performed daily and as needed. During a surveyor's observation, a registered nurse failed to follow proper infection control protocols and did not adhere to the physician's wound care orders. The nurse entered the resident's room without performing hand hygiene, donned gloves, and proceeded with wound care without changing gloves or sanitizing hands between steps. The nurse also omitted key steps in the wound care process, such as applying skin prep and Santyl ointment before the calcium alginate, as ordered. These actions were confirmed by the Assistant Director of Nursing, who acknowledged that hand hygiene and adherence to wound care orders were not followed during the observed care.
Failure to Prevent Accidents and Inadequate Supervision for Residents at Risk
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with a history of cerebral infarction, severe cognitive deficit, generalized weakness, and osteoporosis was assessed as high risk for falls and required dependent assistance with toileting. Despite care plan interventions specifying that staff should remain with the resident while in the bathroom, the resident was left unsupervised for approximately 20 minutes, resulting in an unwitnessed fall. The resident was not observed to use the call light, and staff did not return to check on the resident during this period, contrary to the care plan and facility expectations. Another resident, who is cognitively intact but dependent on staff for toileting hygiene, lower body dressing, and transfers, was not properly assessed for independent vaping or smoking. Although the facility's policy requires an evaluation for all residents who use tobacco products or e-cigarettes, the resident was listed as able to smoke independently without a completed assessment or a care plan addressing vaping or smoking. The resident reported being able to go outside to vape, but the facility had not documented this in the care plan or completed the required assessment at the time of the survey. These deficiencies were identified through observation, interviews, and record reviews, which revealed lapses in following established policies and care plan interventions. The facility did not ensure that residents at risk for falls or those using tobacco products were adequately supervised or assessed, leading to preventable incidents and a lack of appropriate care planning.
Failure to Provide Ongoing Assessment and Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident who required dialysis services. According to the facility's own policy, staff are required to assess the resident's condition and monitor for complications before and after dialysis treatments, including checking vital signs, weight, and the status of the dialysis access site. However, review of the resident's medical record revealed that there was no documentation of comprehensive assessments, such as vital signs, weight, or inspection of the dialysis port site, either before or after the resident returned from dialysis. The medication and treatment administration records only showed weekly vital signs and weights, with no specific documentation related to pre- and post-dialysis care. Interviews with the resident and the Director of Nursing confirmed that staff did not consistently perform or document assessments upon the resident's return from dialysis. The resident reported that staff sometimes checked vital signs after dialysis, but not always immediately upon return. The DON acknowledged that staff did not document assessments after dialysis and that there was no established process for assessing the dialysis port site upon return, as some dialysis facilities preferred the bandage not be removed. The lack of ongoing assessment and monitoring was not consistent with the facility's policy or the resident's care plan.
Infection Control Lapses in Hand Hygiene, PPE Use, and Catheter Bag Management
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene, use of personal protective equipment (PPE), and proper handling of medical devices. During wound care for a resident with multiple pressure injuries and diabetic foot ulcers, a registered nurse did not perform hand hygiene at required intervals, failed to use a gown as part of enhanced barrier precautions (EBP), and used personal supplies without proper disinfection. The nurse also placed contaminated items back into personal storage and did not sanitize equipment after use, contrary to facility policy and infection control standards. In another instance, a certified nursing assistant (CNA) did not perform hand hygiene after removing gloves during incontinence care for a resident, instead proceeding to handle clean items and assist with dressing without sanitizing hands. The CNA acknowledged the lapse when questioned and confirmed that hand hygiene should have been performed between glove changes, as required by facility policy. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag lying on the floor, despite facility policy stating that drainage bags should not touch the floor. Staff were seen handling the bag and placing it back on the floor, and the resident reported that the bag was always on the floor. The care plan for this resident did not address proper placement of the urinary collection bag, and staff interviews confirmed the expectation that the bag should be kept off the floor.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the storage, labeling, and dating of food items, which are essential to prevent foodborne illnesses. During a survey, multiple unlabeled and potentially expired food items were found in the facility's walk-in refrigerator and resident kitchenette. These included containers of Italian dressing, relish, whipping cream, milk, sour cream, and various dressings, some of which lacked open date labels or had expired manufacturer's dates. The Dietary Manager (DM) and Dietary staff admitted to not labeling items with open dates and acknowledged the presence of expired items. The surveyor observed that the facility's policy required all refrigerated and prepared food to be covered, labeled, and dated with a use-by date. However, this policy was not consistently followed, as evidenced by the presence of unlabeled and expired food items. The DM indicated that it was the responsibility of the kitchen staff to monitor the resident fridge, but this was not being done effectively. The DM also mentioned that nursing staff were expected to monitor the fridge, but this was not occurring, leading to expired food items being stored in the resident refrigerator. The Nursing Home Administrator (NHA) was unaware of any foodborne illnesses among staff and residents, but acknowledged the deficiency after being informed by the DM. The DM admitted to the NHA that items in the kitchen were not labeled with open dates and that expired items were found in the kitchen area. This lack of adherence to food safety protocols posed a risk of foodborne illness to the residents, although no illnesses were reported at the time of the survey.
Failure to Convey Deceased Resident's Trust Funds
Penalty
Summary
The facility failed to ensure the timely conveyance of a deceased resident's trust funds to the appropriate party. Specifically, the facility did not return the trust funds of a resident, identified as R1, to the Power of Attorney (POA) or family within 30 days of the resident's death. The facility's policy on Resident Trust Accounts mandates that upon a resident's death, the facility must promptly convey the resident's funds and provide a final accounting to the individual administering the resident's estate. However, a review of R1's account history revealed a positive balance of $180.11, with no documentation of funds being conveyed to the POA. During the survey, a family member of R1, identified as FM C, reported that the facility refused to refund the trust account balance, citing an outstanding balance of $5,000 owed by FM C. The Nursing Home Administrator (NHA) expressed uncertainty about the remaining balance, while the Accounts Receivable Specialist claimed that all trust accounts are typically conveyed within 30 days of discharge or death. Despite this assertion, the funds had not been returned, indicating a lapse in the facility's adherence to its policy and regulatory requirements.
Failure to Report Falls to Physician
Penalty
Summary
The facility failed to immediately report falls to the physician for two residents, leading to a deficiency in communication and care. The first resident, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite being found on the floor and examined for injuries, there was no documentation that the physician or family members were notified of the incident. An investigation later revealed that the nurse on duty did not inform the necessary parties, resulting in disciplinary action against the nurse. The second resident, with diagnoses including dementia and repeated falls, had two unwitnessed falls on 10/09/24 and 10/24/24. There was no documentation of physician notification for either incident. The Director of Nursing (DON) was unaware of the falls until observing the resident with facial bruising. The lack of documentation and communication with the physician regarding the resident's injuries and falls highlights a significant lapse in following the facility's change in condition policy.
Failure to Conduct Proper Assessments After Falls
Penalty
Summary
The facility failed to provide care and treatment according to professional standards of practice for two residents following falls. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall on 09/09/24. The resident was found on the floor tangled in bedding, but the nurse did not perform a thorough assessment, including vital signs, neurological checks, or a head-to-toe examination. The fall was not reported to hospice services or the family until the following day when the resident showed signs of pain and bruising, indicating a possible injury. Resident 2, diagnosed with dementia and at risk for falls, had an unwitnessed fall and another incident where they slid out of a wheelchair. Despite these events, there was no documentation of a comprehensive assessment, including vital signs or neurological checks, in the resident's records. The Director of Nursing was unaware of the falls until observing the resident with facial bruising, suggesting a lack of communication and documentation by the nursing staff. The facility's failure to conduct proper assessments and communicate falls to relevant parties resulted in deficiencies in maintaining the residents' highest practicable level of physical well-being. The lack of documentation and communication highlights a significant gap in the facility's fall management protocol, as outlined in their policy, which requires thorough assessments and timely reporting of falls to physicians and family members.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement new care planned fall interventions for three residents who were at risk for falls. Resident 1, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite a discussion on 09/11/24 to add a fall mat as a new intervention, this was not added to the care plan, and no other interventions were updated following the fall. Resident 2, with diagnoses including dementia and repeated falls, had two falls on 10/09/24 and 10/24/24. The facility did not implement any new interventions after these incidents, despite the resident's care plan being in place since 04/22/24. The care plan included various interventions, but none were updated or added following the falls. Resident 3, who had a history of falling and other medical conditions, fell on 10/21/24. The care plan, initiated in 2018, was not updated with new interventions after the fall. The Director of Nursing acknowledged that no new interventions were implemented for any of the residents after their falls, citing that staff sometimes miss implementing new interventions.
Improper Hand Hygiene and Hair Net Use in Food Service
Penalty
Summary
The facility did not ensure proper hand hygiene and use of hair nets in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a Certified Nursing Assistant (CNA) was observed entering the kitchen without wearing a hair net, despite a sign indicating that hair nets were required. The CNA indicated they were just grabbing coffee, but their uncovered hair could easily fall into the coffee cup, which was located near the cooking and plating areas of the kitchen. Additionally, during the point of service plating before lunch, a Dietary Cook (DC) was observed using gloves to place bread on residents' plates. However, the DC touched their glasses and stove controls without changing gloves or using hand hygiene before continuing to handle the bread. The Dietary Manager (DM) confirmed that they would expect anyone entering the kitchen to wear a hair net and that staff should use tongs or change gloves and wash hands if unclean items are touched during the serving process.
Failure to Schedule Follow-Up Oncology Appointment
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to follow physician orders to schedule a follow-up oncology appointment within 2-4 days after admission for a resident diagnosed with a lesion on the left ninth rib, which could represent metastatic disease. The hospital discharge summary clearly indicated the need for this follow-up, but the facility did not act on these orders in a timely manner. The facility's admission checklist required multiple checks and signatures to ensure all orders were followed, but this process was not effectively executed. The Social Services Assistant, responsible for scheduling appointments, did not receive the necessary information to schedule the oncology follow-up. Interviews with staff, including the DON and RN, revealed that the facility's procedure for scheduling appointments was not followed, and there was confusion about the responsibility for ensuring the appointment was made. The resident confirmed awareness of the oncology referral but was unsure if the appointment had been scheduled. The DON and other staff members acknowledged the oversight and indicated that the facility was waiting for insurance authorization, which had not been communicated effectively. There was no documentation of attempts to schedule the appointment or communicate with other providers until the surveyor's review, indicating a lapse in the facility's protocol and communication processes.
Failure to Supervise Resident During Use of Oscillating Percussion Vest
Penalty
Summary
The facility did not evaluate for hazards or risks related to the use of an oscillating percussion vest for a resident with quadriplegia and a high risk for aspiration. The resident, who has a history of aspiration pneumonia and other severe medical conditions, was observed alone in his room wearing the vest without supervision. The care plan did not address whether the resident was safe to be left alone with the vest or how supervision would be provided during the treatment sessions. Staff interviews revealed that the resident was unable to use a call light to ask for assistance, and there was no clear protocol for ensuring the resident's safety during the vest treatment. The resident's physician orders included the use of the Afflo Respiratory Vest twice daily while sitting up in a wheelchair, with specific instructions to stop tube feeding during the session and check the resident's mouth and lung sounds afterward. However, observations and staff interviews indicated that these orders were not consistently followed. For instance, the surveyor did not observe nursing staff checking the resident's lung sounds after a vest session, and the resident had a large amount of mucus in his mouth that required oral care. The Director of Nursing (DON) confirmed that the resident's care plan did not initially include the use of the chest vest and that an assessment to determine if the resident was safe to wear the vest unsupervised had not been conducted. Despite the manufacturer's instructions indicating that disabled persons should not use the vest without supervision, the facility did not have a clear protocol for supervising the resident during vest treatments. Staff reported that they usually kept the resident by the nurse's station or left his door open for observation, but this was not documented in the care plan or consistently practiced.
Improper Verification of G-Tube Placement During Medication Administration
Penalty
Summary
The facility did not ensure that residents who are medicated by enteral means received the appropriate treatment to prevent complications during medication administration through a Gastric tube (G-tube). This was observed with one resident who received medication without ensuring the G-tube was appropriately placed prior to medication administration. The resident, who had diagnoses of epilepsy, cerebral palsy, and functional intestinal disorder, was observed receiving valproic acid via G-tube without proper verification of tube placement according to current standards of practice. The Licensed Practical Nurse (LPN) administering the medication used an outdated method of injecting air into the G-tube and listening for noise to check for proper placement. This method is no longer the standard of practice, as confirmed by the surveyor and the Director of Nursing (DON). The facility's policy, last revised in March 2020, still included this outdated practice, leading to the deficiency observed during the survey.
Infection Control Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Staff failed to perform proper hand hygiene during medication administration with a resident who had a severe cognitive impact. Specifically, a registered nurse did not perform hand hygiene before and after administering medications to the resident and proceeded to check another resident's blood sugar without proper hand hygiene initially. This was observed by a surveyor and confirmed by the Director of Nursing, who acknowledged that the nurse should have performed hand hygiene between residents. Additionally, the facility prematurely removed droplet precautions for a resident who tested positive for COVID-19. The resident was supposed to remain on droplet precautions for ten days following the onset of symptoms, but staff miscounted the isolation days, leading to the removal of precautions one day early. This error was identified when the surveyor observed the resident on contact precautions instead of droplet precautions. The Assistant Director of Nursing confirmed that the miscalculation occurred because staff did not count the first day of isolation as day zero, resulting in the premature removal of droplet precautions.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
