Monroe Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Wisconsin.
- Location
- 516 26th Ave, Monroe, Wisconsin 53566
- CMS Provider Number
- 525292
- Inspections on file
- 22
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Monroe Health Services during CMS and state inspections, most recent first.
A resident's cell phone was misappropriated by a housekeeper, who was later terminated based on evidence, although the theft could not be conclusively proven. The resident, who was cognitively intact, reported seeing the housekeeper take the phone. The facility's policy on abuse prevention was not effectively implemented, and the contracted housekeeping company failed to provide adequate follow-up training to its staff.
A resident with Chronic Kidney Disease Stage 4 had critical lab results that were not communicated to a provider. The facility's process for handling lab results broke down, as the Nurse Practitioner was on vacation and the on-call provider was not notified. Staff interviews revealed no specific timeframe for checking lab results, and the Director of Nursing expected follow-up that did not occur.
A resident with a history of osteoporosis was found with a bruise on her arm, which was not reported to the State Agency within the required timeframe. The facility's policy requires immediate reporting of such incidents, but the Nursing Home Administrator and Director of Nursing delayed reporting until the resident's family alleged abuse. An x-ray later revealed a fracture, highlighting a deficiency in the facility's reporting procedures.
A facility failed to create a comprehensive care plan for a resident prescribed Melatonin for insomnia. The care plan did not include the medication, and there was no sleep assessment or tracking to evaluate its effectiveness. Interviews with facility staff confirmed the absence of necessary assessments and monitoring.
A resident with essential hypertension had physician orders for daily weights over seven days, but the facility failed to document weights on three days. Despite this, the MAR was signed for all days, indicating a discrepancy. Interviews with staff confirmed that weights should be documented in the PCC system daily, but this was not done, leading to a failure in following physician orders.
The facility failed to provide adequate wound care and post-fall assessments for residents. Two residents did not receive documented wound care as per orders, and a resident who fell was moved without a complete RN assessment, leading to a missed fracture diagnosis.
A resident with a stage 3 pressure wound on the left calf did not receive prescribed treatment due to a failure to transcribe the wound care order onto the Treatment Administration Record (TAR). The treatment, which included the application of Leptospermum honey and a secondary dressing, was not completed on multiple days. The Director of Nursing confirmed the lapse in documentation and treatment, acknowledging that if it was not documented, it was not done. Despite this, the resident's wound did not worsen during the period of non-compliance.
Two residents experienced medication administration errors, resulting in a 5.88% error rate. An RN failed to assess vital signs before administering Lisinopril, and an LPN gave Omeprazole with breakfast instead of one hour prior, both against physician orders.
A resident with severe cognitive impairment and multiple falls had inaccurate fall risk assessments in their medical records. Despite being on medications that increased fall risk, assessments often indicated a low risk. Interviews with staff revealed inconsistencies in the assessment process, and the DON acknowledged the inaccuracies.
A resident was given an antibiotic for a suspected UTI before urine culture results were finalized. The culture showed mixed flora with no specific bacteria, yet the antibiotic treatment continued without consulting the physician or recollecting a sample. The ADON/IP relied on the CFU/ml result, and the DON expected physician consultation, highlighting a failure in the facility's antibiotic stewardship program.
Misappropriation of Resident's Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically a cell phone, by a housekeeper. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. The resident reported seeing a housekeeper take her phone and put it in her pocket. The phone was later found in the car of another housekeeper, with whom the accused housekeeper was carpooling. Despite the resident's clear account of the event, the facility and police were unable to substantiate the theft, but the housekeeper was terminated based on the evidence. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the misappropriation of the resident's property. The facility's response included suspending the housekeeper and involving the police, but the investigation did not conclusively prove the theft. Interviews with staff and the resident confirmed the resident's account, but the facility's contracted housekeeping company did not provide adequate follow-up training or reeducation on abuse prevention to its staff. The incident highlighted a gap in the facility's oversight of contracted staff, as the housekeeping company was responsible for background checks and training. The facility's administration and nursing staff were involved in the investigation, but there was a lack of coordination with the contracted housekeeping company to ensure all staff received necessary abuse prevention training. This deficiency in communication and training contributed to the failure to protect the resident's property effectively.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, as evidenced by the lack of notification regarding abnormal lab results for a resident. The resident, who was admitted with multiple diagnoses including Chronic Kidney Disease Stage 4, had lab results showing significantly elevated Blood Urea Nitrogen (BUN) and Creatinine levels, and a low Glomerular Filtration Rate (GFR). Despite these critical findings, there was no evidence that the lab results were communicated to or reviewed by a provider. Interviews with facility staff revealed a breakdown in the process of handling lab results. The Nurse Practitioner who ordered the labs was on vacation, and the facility did not notify the on-call provider of the results. The Director of Nursing and Unit Manager indicated that there was no specific timeframe for checking lab results, and the Unit Manager did not recall the resident's labs. The Director of Nursing expected staff to follow up with the provider once lab results were received, but this did not occur, leading to a failure in addressing the resident's critical condition in a timely manner.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime in accordance with section 1150B of the Act, specifically regarding an injury of unknown origin for a resident, identified as R10. R10, who has a medical history including Alzheimer's disease, osteoporosis, dementia, generalized anxiety disorder, and major depressive disorder, was found with a bruise on her upper right arm on 7/7/24. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the State Agency until 7/11/24, which is beyond the required timeframe. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately, but not later than 24 hours if the events do not involve abuse or result in serious bodily injury. However, the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not adhere to this policy. The NHA reported the incident only after R10's family alleged abuse, despite being aware of the injury on 7/7/24. The DON initially assessed the bruise as small and not of unknown origin, attributing it to changing R10's clothing, but later acknowledged the bruise had grown significantly by 7/8/24. The delay in reporting was further compounded by the facility's decision to pursue an x-ray only after the family insisted, which revealed a fracture with displacement of the humeral head. The NHA and DON both acknowledged the reporting delay, with the DON stating that the injury should have been reported immediately, especially when physical harm is alleged. The facility's failure to report the injury within the required timeframe constitutes a deficiency in their reporting procedures.
Failure to Develop Comprehensive Care Plan for Resident on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R35, who was prescribed Melatonin for insomnia. Despite the resident's cognitive intactness and existing diagnoses of weakness, obstructive sleep apnea, and depression, the care plan did not include any mention of Melatonin use. The facility's policy mandates that care plans should include measurable objectives and timeframes to meet the resident's needs, but this was not adhered to in R35's case. The care plan, dated February 2024, only mentioned sleep cycle issues related to depression without addressing the Melatonin prescription. Additionally, there was no sleep assessment or sleep tracking documented for R35, which is crucial to evaluate the effectiveness of the Melatonin treatment. The Medication Administration Record from May to July 2024 lacked any documentation of sleep tracking or the effectiveness of the medication. Interviews with the Vice President of Success and the Director of Nursing revealed that the facility did not conduct a sleep assessment for R35, and the Director of Nursing acknowledged the necessity of sleep monitoring for residents on sleep medication.
Failure to Document Daily Weights as Ordered
Penalty
Summary
The facility failed to meet professional standards of quality by not adhering to physician orders for daily weight monitoring of a resident, identified as R40, who was admitted with essential hypertension. The physician had ordered daily weights for seven days, but the facility did not complete this task on three of those days. Despite the absence of weight documentation for these days, the Medication Administration Record (MAR) was signed for all seven days, indicating a discrepancy between recorded actions and actual practice. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), revealed that weights should be documented in the Point Click Care (PCC) system on the same day they are taken. The DON confirmed that the facility's policy requires weights to be documented in PCC to ensure that any significant weight changes are communicated to the physician. However, the lack of documentation for three days meant that the facility did not follow the physician's orders, and staff would not have been aware of any necessary updates to the physician regarding weight changes.
Deficiencies in Wound Care and Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. For two residents with non-pressure wounds, there were multiple instances where wound care treatments were not documented as completed on the Treatment Administration Record (TAR). One resident, who was cognitively intact, had specific orders from a wound doctor that were not transcribed onto the TAR or completed, leading to gaps in wound care. Another resident had similar issues with wound care treatments not being documented, indicating they were not completed as per the orders. Additionally, the facility did not conduct a thorough assessment following a fall for a resident who later was found to have a fracture. The resident, who had a history of hemiplegia and osteoporosis, fell while reaching for a cupcake. The resident was moved from the floor to a wheelchair and later to a bed without a complete assessment by a Registered Nurse (RN). The documentation provided was inconsistent and lacked a full physical assessment, which is required after a fall. Interviews with facility staff, including the Director of Nursing (DON) and the Infection Preventionist/Wound Nurse, revealed that there were lapses in the process of entering and completing wound care orders. The DON confirmed that if treatments are not documented, they are considered not done. Furthermore, the RN involved in the post-fall incident admitted to not completing a full assessment and moving the resident without proper evaluation, which is against the facility's policy for fall management.
Failure to Administer Pressure Ulcer Treatment as Ordered
Penalty
Summary
The facility failed to implement professional standards of practice for pressure ulcer care for a resident, identified as R147, who was reviewed for pressure injuries. The resident, who was admitted with a stage 3 pressure wound on the left calf, had a treatment plan prescribed by a wound doctor, which included the application of Leptospermum honey and a secondary dressing of gauze island with a border, to be applied once daily for 23 days. However, this order was not transcribed onto the resident's Treatment Administration Record (TAR) and was not completed as ordered on multiple days. The facility's policy requires that new medication orders be documented in the resident's medical record and entered into the TAR. Despite this, the treatment for R147's pressure injury was not documented or completed from 5/21/24 to 6/6/24. The Director of Nursing (DON) confirmed that the orders were not on the TAR during this period and acknowledged that if it was not documented, it was not done. Although the resident's wound did not worsen during the time the treatment was not completed, the facility did not adhere to its policy of administering treatments as ordered and monitoring for effectiveness.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 5.88%, exceeding the acceptable threshold of 5%. This was based on two errors observed during a medication pass task involving two residents. The first error involved a registered nurse (RN) who administered Lisinopril to a resident without assessing the resident's vital signs, as required by the physician's orders. The orders specified that the medication should be held if the resident's systolic blood pressure was below 100, diastolic blood pressure was below 60, or heart rate was below 60. The RN admitted to not taking the vital signs on the day of the observation, despite being aware of the hold parameters. The second error involved a licensed practical nurse (LPN) who administered Omeprazole to another resident with breakfast, contrary to the physician's orders that specified the medication should be given one hour before breakfast. The LPN acknowledged the error during an interview with the surveyor. The Director of Nursing confirmed that medications should be administered as ordered and recognized both instances as medication errors. The facility's policy on medication administration was not adhered to in these cases, leading to the identified deficiencies.
Inaccurate Fall Risk Assessments for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as R39, who was at high risk for falls. R39's medical records contained inaccurate fall risk assessments following five falls within the facility over a three-month period. The resident was admitted with diagnoses including encephalopathy, vascular dementia, and polyneuropathy, and was severely cognitively impaired with a BIMS score of 3 out of 15. Despite these conditions and a history of falls, the fall risk assessments inaccurately reflected the resident's fall risk level, often indicating a low risk when the resident had multiple falls and was on medications that increased fall risk. The post-fall assessments for R39 were inconsistent and did not accurately document the number of falls or the medications that contributed to the fall risk. For instance, one assessment indicated no falls in the past 30 days and 1-2 falls in the past 90 days, when the resident had actually experienced three falls. Additionally, the assessments failed to account for medications such as a diuretic, laxative, psychotropic medication, and antidepressant, which were known to increase fall risk. This lack of accurate documentation and assessment led to an underestimation of the resident's fall risk. Interviews with facility staff, including an LPN, RN, and the DON, revealed a lack of consistency in the fall risk assessment process. Staff acknowledged that recent falls and certain medications should increase a resident's fall risk, yet the assessments did not reflect this understanding. The DON admitted that the fall risk assessments for R39 were not accurate and should have been completed correctly. This deficiency in maintaining accurate medical records and assessments compromised the facility's ability to effectively manage and mitigate the resident's fall risk.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program, which is part of its infection prevention and control program, by not following antibiotic use protocols and failing to monitor antibiotic use effectively. A resident, identified as R2, was administered an antibiotic, cefuroxime, for a suspected urinary tract infection (UTI) before the urine culture results were finalized. The urine culture results, which were available the day after the antibiotic was started, indicated mixed flora with no specific bacteria isolated, and suggested recollection if clinically indicated. Despite this, the antibiotic treatment continued without further consultation with the physician or recollection of a urine sample. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) and the Director of Nursing (DON) were interviewed and acknowledged the oversight. The ADON/IP admitted to relying solely on the >100,000 CFU/ml result for treatment, while the DON expressed that the expectation would have been to contact the physician to discuss the results and consider recollecting a urine sample. The facility's failure to reassess the need for antibiotics after receiving the culture results, which did not confirm a specific infection, led to the continuation of unnecessary antibiotic treatment for R2.
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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