Newcastle Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Mequon, Wisconsin.
- Location
- 12600 N Port Washington Rd #300, Mequon, Wisconsin 53092
- CMS Provider Number
- 525668
- Inspections on file
- 24
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Newcastle Place during CMS and state inspections, most recent first.
The facility failed to provide adequate supervision, assistance devices, and thorough post-incident investigations for multiple residents at high risk for falls and other accidents. One resident with Parkinson’s disease, orthostatic hypotension, recent severe functional decline, and a documented high fall-risk score was admitted without initiation of a high-risk fall care plan or resident-specific interventions; after seizure-like activity and documented confusion and wandering overnight, the resident was later found on the floor with head trauma, and the facility’s investigation did not establish when the resident was last seen or toileted, nor obtain statements from prior-shift staff. Another cognitively impaired resident with a history of falls and multiple comorbidities, already on a fall care plan, slid from a chair while fidgeting after an activity; the original fall investigation omitted key details such as last toileting and reasons for the fidgeting, and the post-fall evaluation’s contributing factors were left blank until a later addendum, while observations showed that several care-planned fall interventions (e.g., bilateral floor mats, body pillow, bed pillows) were not in place. Additional residents experienced a burn from hot soup without a prior hot-liquid assessment and falls without thorough root-cause analysis, and were observed without their care-planned fall or accident-prevention interventions, demonstrating repeated failures to follow the facility’s own fall mitigation program and to consistently implement and investigate safety measures.
Two residents did not receive care in accordance with professional standards and physician orders. One resident with severe cognitive impairment spilled hot soup on the torso and hand; an LPN documented redness, pain, and vital signs and noted that the provider’s office was notified, but there was no evidence of direct physician contact that day, no treatment order until the next day, and no RN assessment of the burn until several days later, despite the development of blisters and an in-house full-thickness burn. Another resident was admitted with physician orders for an admission weight and daily weights for two days, but the MAR showed the ordered admission and daily weights were not obtained, and the DON acknowledged that these physician orders were not followed.
Two residents with PICC lines did not receive care in accordance with physician orders and facility policy. One resident was admitted with a PICC placed in the left arm, but no PICC-related physician orders or care plan were obtained for eight days, and admission assessments and skin checks failed to document the presence or condition of the line despite hospital records specifying its placement and measurements. Another resident with complex orthopedic and infectious conditions had detailed PICC orders for dressing and cap changes, line flushing, site monitoring, and measurements of external catheter length and arm circumference, yet treatment administration records showed multiple dates and shifts where these ordered interventions were left blank without explanatory documentation. Staff interviews confirmed that nurses are expected to complete and sign out treatments on the TAR, but they could not explain the missing orders and undocumented PICC care.
A resident with multiple medical conditions, including hypokalemia, had an active order for Potassium Chloride ER 10 mEq that was not administered for three consecutive days. An LPN contacted the pharmacy and was told the medication had been delivered and signed for by another nurse, but the drug could not be located on the med cart or in the med room. Although the facility’s policy required checking contingency stock, contacting the pharmacy, and obtaining provider guidance to prevent missed essential medications, the ordered Potassium Chloride was still not given during this period, and the DON later reported being unaware that the resident had gone without the medication.
Staff left whole medications at the bedside for a severely cognitively impaired resident with metabolic encephalopathy and hypertension without conducting a self-administration assessment, obtaining an MD order, or developing a related care plan, despite facility policy requiring an IDT-based determination of decision-making capacity before allowing self-administration. The resident’s family later found two pills on the bedside table, which a nurse indicated might have been antihypertensive medication, and the Administrator acknowledged the resident would not have been able to self-administer medications.
A resident with severe cognitive impairment and HTN was ordered carvedilol 25 mg PO BID with no authorization for self-administration. An LPN documented giving the evening dose, but whole medications, later identified by family as likely carvedilol and atorvastatin, were left in a medicine cup at the bedside. The next morning, family gave the resident the bedside pills before an LPN arrived to pass meds. While the LPN was administering the scheduled crushed carvedilol dose in applesauce, the family reported the earlier ingestion and described the pills, which the LPN confirmed were likely the resident’s BP medication from the prior shift. The LPN completed administration of the carvedilol in applesauce, after which the resident became drowsy, then unresponsive, with a marked drop in BP and was sent to the ED with hypotension and bradycardia attributed to two doses of carvedilol taken that morning.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report does not specify further details about the residents or staff involved.
Two residents with intact cognition reported missing money and personal property, but the facility did not notify law enforcement or the State Agency as required. Staff documented the incidents and informed the administrator, but there was no evidence of timely reporting to authorities, and the facility did not follow its own abuse and misappropriation reporting policies.
The facility did not thoroughly investigate two separate allegations of misappropriation of resident property. In both cases, residents with intact cognition reported missing money and personal items, but the facility failed to conduct comprehensive investigations, including staff interviews and proper documentation, as required by policy.
A resident independently administered pain medication and insulin brought from home due to a delay in the facility's pharmacy delivery. Staff interviews confirmed that the resident was offered facility-supplied insulin but chose to use their own, and the use of home medications was not documented in the medical record as required by facility policy.
Staff did not consistently wear required hair or beard restraints in food preparation and service areas, and failed to ensure the dishwasher reached proper sanitizing temperatures or document the use of temperature strips. Additionally, staff did not properly test or document the quaternary sanitizing solution in the three-compartment sink, using incorrect test strips and failing to check water temperature as required.
The facility did not conduct required reference checks for four newly hired CNAs, as mandated by its abuse, neglect, and exploitation policy. Staff interviews confirmed that reference checks were not part of the hiring process, and documentation was not maintained, resulting in noncompliance with facility policy.
Four residents with complex medical histories, including diabetes and respiratory conditions, were not offered or administered the PCV20 pneumococcal vaccine despite being eligible under CDC guidelines. The Infection Preventionist was unaware of the updated vaccination requirements and there was no system in place to ensure the PCV20 vaccine was offered.
A resident with a recent BKA and multiple comorbidities did not receive wound care as ordered, with the dressing not changed for several days after admission despite documentation indicating otherwise. The resident also did not have vital signs monitored daily as required by facility policy, and staff interviews confirmed lapses in both care delivery and documentation.
A resident with a history of falls and significant mobility and cognitive impairments did not have their walker kept within reach as required by their care plan. Despite recent falls and documented risk factors, staff did not consistently follow the intervention, and multiple staff members confirmed the walker was not accessible to the resident during observations.
Two residents with PICC lines did not have their dressings and injection caps changed as ordered, despite documentation indicating the tasks were completed. Direct observation and interviews confirmed that the required weekly changes were missed or delayed, contrary to physician orders and facility policy.
Staff did not consistently use required PPE, including gown and gloves, while providing high-contact care to a resident on Enhanced Barrier Precautions for chronic wounds. Despite clear policy, signage, and care plan instructions, CNAs and a restorative aide were observed and admitted to providing care and transfers without proper PPE, and staff interviews confirmed a lack of adherence to infection control protocols.
A facility failed to report a verbal abuse incident involving an LPN and a resident with moderate cognitive impairment. The LPN was witnessed yelling derogatory terms at the resident, who was crying for help. Despite the facility's policy requiring immediate reporting to law enforcement, the incident was not reported. Multiple staff members observed the LPN's abnormal behavior, raising concerns about possible intoxication.
A facility failed to thoroughly investigate a verbal abuse allegation involving a resident with dementia. An LPN was observed verbally abusing the resident, but the investigation lacked interviews with key individuals, notification to law enforcement, and updates to the resident's care plan. The Nursing Home Administrator did not initially provide abuse education, considering it an isolated incident.
A resident did not receive prescribed heparin injections as ordered, with several doses missing from the MAR and no progress notes explaining the omissions. Despite having access to contingency medication and the ability to request STAT orders, the facility failed to administer the medication correctly. Interviews revealed that the Omnicell machine did not record any heparin removal, indicating a lapse in medication administration and documentation.
A CNA failed to follow proper infection control procedures during incontinence care for a resident by not removing gloves and performing hand hygiene after perineal care. The CNA touched various items in the resident's room without cleansing hands, contrary to the facility's hand hygiene policy. The DON confirmed the expectation for staff to perform hand hygiene after removing soiled gloves.
The facility failed to implement its abuse policy for three employees by not completing required background checks. An RN's background check was outdated, and the facility lacked background information for a DM and CNA who were contracted staff.
The facility failed to notify a physician of a resident's low irregular heart rate and low blood pressure and did not follow physician orders for daily weights. The resident was later admitted to the ICU for hypotension.
The facility failed to ensure staff used gait belts during transfers for four residents, despite the expectation and policy to do so. Observations and interviews confirmed that staff often did not use gait belts, compromising resident safety.
The facility failed to ensure accurate medication administration for three residents, leading to missed doses and improper documentation. One resident did not receive timely pain medication, another missed four doses of prescribed medication upon admission, and a third missed two doses due to unavailability. Staff interviews confirmed these issues and highlighted challenges in the medication delivery process.
A resident was administered Benadryl for sleep instead of its prescribed use for itching. The resident, who had intact cognition and multiple diagnoses, requested Benadryl to help sleep. An agency nurse administered it despite the resident not experiencing itching. The facility's policy and nursing leadership confirmed that the medication should only be administered for its prescribed reason.
The facility failed to report allegations of abuse, neglect, or injury to the State Agency and local law enforcement in a timely manner for five residents. Delays were due to administrative oversights and lack of access to reporting portals, leading to non-compliance with regulatory requirements.
The facility failed to thoroughly investigate allegations of abuse for six residents. Investigations lacked interviews with other residents and staff, and in some cases, the accused staff were not removed from resident care pending the investigation's outcome. Additionally, investigations did not summarize or identify the cause of injuries or complete necessary staff education.
The facility failed to protect a resident from abuse by not implementing interventions after staff voiced concerns about a CNA's behavior. Despite reports of abuse and staff identifying the CNA as rude and unkind, the CNA continued to work without documented intervention. The CNA was later implicated in an incident where a resident reported being thrown around in bed, resulting in bruising. The facility lacked documentation and thorough investigation, leading to the CNA's termination.
Failure to Implement Fall and Accident Prevention Measures and Conduct Thorough Post-Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received adequate supervision and assistance devices to prevent accidents, and failure to conduct thorough post-incident investigations to determine root causes. One resident was admitted with multiple fall risk factors, including Parkinson’s disease, orthostatic hypotension, a history of falls, recent hospitalization for syncope and hypotension, and a documented significant decline in functional status requiring maximal assistance with transfers and ambulation per hospital therapy assessments. On admission, the facility’s own fall risk evaluation scored this resident at a high-risk level, and the admission assessment documented unsteady gait, prior falls, intermittent confusion associated with hypotensive episodes, and some forgetfulness. Despite this, the facility did not initiate a high-risk fall care plan or resident-specific fall interventions as directed by its fall mitigation policy, and no interventions were triggered from the admission assessment. During the first night after admission, the resident experienced seizure-like activity with unresponsiveness, after which staff documented confusion and, per CNA interview, wandering in the hallway requiring redirection back to the room. Staff reported this information in shift report, including that the resident had been trying to self-transfer and was wandering. The following morning, an LPN starting the day shift found the resident on the floor in the room with a large hematoma above the left eye, blood on the face and floor, and multiple skin tears, and documented that the resident reported dizziness and had an initial low blood pressure. The facility’s risk management entry described the resident on the floor between the bed and bathroom door, a spilled urinal on the floor, the bedside table pushed toward the bathroom doorway, bare feet with slippers on the floor, and the call light not engaged. However, the investigation did not document when the resident was last seen, when the resident was last toileted or assisted, or obtain statements from prior-shift staff, despite those staff having information about the resident’s confusion, wandering, and self-transfer attempts. The IDT note later stated the resident was self-transferring and/or slipped out of bed while using a urinal and that the care plan was followed, even though no fall care plan had been initiated at the time of the fall. Another resident with dementia, a history of falling, CKD, depression, syncope and collapse, osteoporosis, and osteoarthritis had been assessed as high risk for falls and had a fall care plan that included bilateral floor mats, pillows on both sides of the bed, a body pillow to simulate a spouse, a low bed, nonskid socks, and assistance with toileting. This resident experienced a witnessed fall when sliding from a chair in a TV area while adjusting position; documentation and subsequent interviews indicated the resident was fidgety, had just returned from an activity, and was wearing shoes, but the original fall investigation did not record what was on the resident’s feet, when the resident was last toileted, when the resident was last seen before the fall, or why the resident was shifting or reaching forward. The post-fall evaluation’s contributing factors section was left blank at the time and only later hand-completed as an addendum. Additionally, during multiple observations, the surveyor noted that this resident did not have all care-planned fall interventions in place, including missing one floor mat, the body pillow, and pillows on both sides of the bed. Across these events, the facility did not follow its fall mitigation policy requiring immediate initiation of prevention protocols for high-risk residents, did not consistently implement existing fall care plan interventions, and did not complete thorough post-fall investigations to identify accurate root causes. A third resident sustained a burn from hot soup served by facility staff, and the facility had not completed a hot liquid assessment prior to the burn. When observed by the surveyor, this resident did not have the hot liquid and fall care plan interventions in place. A fourth resident, also assessed as high risk for falls, had a fall that was not thoroughly investigated to determine a root cause, and the surveyor observed that this resident did not have fall prevention care plan interventions in place. For these residents, the report notes that the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents, and that fall or accident investigations were incomplete, lacking key information such as last toileting, last observation time, and contributing environmental or clinical factors, which prevented accurate determination of root causes.
Failure to Timely Assess Burn Injury and Follow Physician Orders for Weights
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. One resident with hypertension, muscle weakness, Alzheimer’s disease, dementia, and anxiety, and a BIMS score indicating severe cognitive impairment, spilled hot soup on the right abdomen, right lower breast, and left pinky. An LPN documented on the day of the incident that the skin was “fire engine red” with no broken skin or blisters, vital signs were taken, pain was rated 6/10, Tylenol was given, and a cool compress applied. The note also states that the on-call provider, POA, and the physician’s office were notified, and that the plan was to assess every shift for three days. However, there is no evidence in the record that the nurse actually spoke with the physician that day, and no treatment order was obtained until the following day. The next day, the LPN documented the development of scattered clear-filled blisters and redness on the abdomen and breast, and recorded that an after-hours physician was notified and gave a verbal order for Vaseline and a bordered foam dressing. A late entry note the following day described all blisters as open and documented cleansing and dressing of the area, with the resident reporting discomfort during the dressing change. Subsequent notes described the dressing not intact, the resident holding the area due to discomfort, and the wound as beefy red but without signs of infection. A physician face-to-face visit and new wound care orders were documented several days after the initial burn. A skin assessment by the unit manager/RN later characterized the wound as a new, full-thickness burn acquired in-house, with pain, erythema, and a wound bed described as 50% epithelial and 50% eschar. The surveyor noted that the burn was not assessed until three days after the incident and that there was no RN assessment until six days after the burn, and the DON acknowledged that floor nurses, whether LPN or RN, had been performing initial assessments rather than an RN. The second deficiency concerns the facility’s failure to obtain ordered admission and daily weights for another resident. This resident was admitted with physician orders for a one-time admission weight and daily weights for two days on the day and days following admission. Review of the MAR for the admission month showed that the admission weight entry was blank on the admission date and the daily weight entries were blank on the two subsequent days, indicating that the ordered weights were not obtained. When informed by the surveyor, the DON confirmed that the weights should have been obtained and that physician orders should have been followed.
Failure to Obtain and Follow PICC Line Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe, appropriate administration and management of PICC lines and IV-related care for two residents in accordance with physician orders and the facility’s own central venous catheter policy. For one resident (R7), who was admitted with a PICC line placed in the left basilic vein for chemotherapy/infusions, the facility did not obtain any physician orders for PICC care or monitoring at the time of admission and did not develop a PICC-related care plan until eight days later. The admission clinical assessment section specific to PICC line care (including PICC care profile, length, solution, location, patency, and site) was left incomplete, and multiple skin assessments and the admission nurse’s note failed to document the presence or condition of the PICC line, despite hospital records clearly indicating its placement and measurements. During interviews, nursing staff could not explain why PICC orders were missing for several days after admission, and the DON later acknowledged that there were no hospital orders for the PICC line and that the PICC should have been identified and documented during the skin assessment. For the second resident (R1), who had complex orthopedic and infectious diagnoses including left total hip and knee arthroplasty with antibiotic spacers and a history of polymicrobial and fungal infection, the facility did not consistently follow existing physician orders for PICC line care and monitoring. R1 had multiple detailed orders, including weekly PICC dressing and injection cap changes, flushing PICC lumens every shift with normal saline, monitoring the PICC site every shift for signs and symptoms of infection, measuring external catheter length weekly, and measuring left arm circumference above the insertion site every shift with notification of the MD for changes. Review of the January and February treatment administration records (TARs) showed multiple dates and shifts where these ordered treatments and assessments were left blank, indicating they were not documented as completed. On several specific dates, required dressing changes, cap changes, external length measurements, arm circumference measurements, site monitoring, and line flushes were not initialed on the TAR. The facility’s own policy on central venous catheter care requires site care and dressing changes at established intervals or when compromised, daily assessment of the entire infusion system and insertion site, evaluation for signs of complications, and measurement of external catheter length and arm circumference for PICCs when indicated. Despite this, for R7, there were no initial orders or care plan elements to operationalize these requirements, and the PICC line was omitted from admission and subsequent skin assessments. For R1, although appropriate orders were in place, the nursing staff did not consistently document completion of the ordered PICC-related treatments and monitoring on multiple dates, and there were no progress notes explaining why the physician orders were not followed. When questioned, a unit manager stated that the expectation is that completed treatments are signed out on the TAR or documented in a note, underscoring that the missing initials represented a failure to carry out or document the ordered PICC care. Interviews with staff further clarified the gaps in practice. R7 reported that staff flushed her PICC line daily and showed the surveyor a dressing dated several days after admission, but this care was not supported by timely physician orders or a care plan at the time of admission. LPNs caring for R7 were unable to explain the delay in obtaining PICC orders. The unit manager indicated that the admitting nurse is responsible for completing orders and that unit managers typically ensure orders are complete, yet the omission of PICC orders persisted for eight days. For R1, review of progress notes on dates where PICC orders were not initialed revealed no documentation explaining missed or omitted treatments. A unit manager confirmed that the expectation is that nurses sign out treatments on the TAR, highlighting that the blank entries represented noncompliance with physician orders for PICC care and monitoring.
Failure to Ensure Availability and Administration of Ordered Potassium Supplement
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services to ensure that ordered medications were available and administered as prescribed for one resident. The resident was admitted with diagnoses including hyperlipidemia, hyperosmolality, and hypernatremia, and had a physician’s order, effective 12/9/25, for Potassium Chloride Crys ER 10 mEq for hypokalemia. Review of the Medication Administration Record showed that the resident did not receive the ordered Potassium Chloride on 12/27, 12/28, and 12/29/25. On 12/27/25, an LPN documented calling the pharmacy about the Potassium Chloride, being informed it had been delivered on 12/23 and signed for by another LPN, and then checking the medication cart and medication room without finding the medication. The LPN documented that the on-call physician was updated and gave verbal approval to administer the medication when it arrived. The facility’s written policy on providing pharmacy products and services required that staff contact the pharmacy 24/7 and, when medications were ordered while the pharmacy was closed, attempt to use emergency supply, consult the prescriber about delaying therapy until the next morning if possible, or contact the pharmacy’s emergency number if the medication was essential and could not be substituted or delayed. During interview, the DON described the expected process when a medication is not available: the nurse should first check contingency stock, then call the pharmacy, and contact the provider for an intervention, with the expectation that no resident goes without prescribed medication. The DON was unaware that the resident had gone without Potassium Chloride for three days and stated that the resident’s health care power of attorney should have been notified of the missed doses. The surveyor confirmed through record review and interviews that the ordered Potassium Chloride was not administered for three consecutive days despite the facility’s policies and stated expectations for ensuring medication availability and administration.
Failure to Assess and Authorize Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
Facility staff failed to follow their medication administration policy requiring an assessment and physician authorization before allowing residents to self-administer medications. The policy stated that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined they had the decision-making capacity to do so safely. One resident was admitted with diagnoses including metabolic encephalopathy and hypertension, and the admission MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. Despite this, whole medications were left at the bedside over a weekend without any documented assessment of the resident’s ability to self-administer medications. An incident note documented that the resident’s daughter found two pills in the resident’s room on the bedside table, which a nurse indicated might have been blood pressure medication. Review of the resident’s care plan showed there was no care plan addressing self-administration of medications, and review of assessments confirmed the resident had not been evaluated for self-administration. Additionally, physician orders did not include any order to leave medications at the bedside for the resident to self-administer. In an interview, the Administrator acknowledged that the resident would not be able to self-administer medications and noted the resident had previously lived in a memory care unit before admission to the skilled nursing unit.
Duplicate Carvedilol Doses Left at Bedside Lead to Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when duplicate doses of a prescribed blood pressure medication were administered. The resident had diagnoses including metabolic encephalopathy and hypertension and was assessed as severely cognitively impaired with a BIMS score of 5/15. The resident had an order for carvedilol 25 mg by mouth twice daily with meals for hypertension, scheduled for morning and evening, and there was no order or care plan for self-administration of medications. According to the Medication Administration Record, an LPN documented administering the resident’s evening medications, including carvedilol, on the day prior to the incident. The facility’s investigative summary later determined that whole medications, identified by the resident’s daughter as likely carvedilol and atorvastatin, had been left at the bedside by staff from a previous shift. On the morning of the incident, family members arrived and found a couple of pills in a medicine cup on the bedside table; the daughter reported that the resident ingested these pills before the nurse began the morning medication pass. While the LPN was administering the scheduled morning dose of carvedilol crushed in applesauce, the daughter informed the nurse that the resident had just taken two pills from the bedside. The LPN checked the MAR and, after comparing pill appearance with the daughter’s description, concluded the pills were likely the resident’s blood pressure medication from the prior evening. Despite this, the crushed carvedilol dose in applesauce was administered. Within approximately 30–45 minutes, the resident became drowsy, then unresponsive to verbal and tactile stimuli, and vital signs showed a significant drop in blood pressure (78/54) with altered consciousness. The resident was transferred to the ED, where records indicated hypotension and bradycardia after taking two doses of carvedilol earlier that day.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No additional information regarding the medical history or condition of any resident at the time of the deficiency is included.
Failure to Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of suspected misappropriation of resident property, as required by section 1150B of the Act. In two separate cases, residents with intact cognition reported missing money and personal property. In the first case, a resident and their family reported $40 and a silver dollar coin missing to a registered nurse, who documented the report and informed the Nursing Home Administrator (NHA) and the on-call nurse. However, there was no documentation that local law enforcement was notified, and the NHA indicated that although the nurse offered to call law enforcement, the resident and family declined, with no documentation to support this claim. In the second case, another resident reported $280 missing from their room. The incident was reported to staff, and the NHA was made aware, but there was no evidence that the allegation was reported to the State Agency or local law enforcement. The NHA provided a $200 gift card to the resident but had little knowledge of the details of the allegation, and the social worker was reportedly working on a grievance that was not yet on file. In both cases, the facility did not follow its own policy requiring the reporting of such allegations to the appropriate authorities within specified timeframes.
Failure to Investigate Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property for two residents. In the first case, a resident with intact cognition reported missing $40 and a silver dollar coin at the time of discharge. The incident was documented by a registered nurse and reported to the Nursing Home Administrator (NHA) and on-call nurse. While the facility interviewed several residents and audited rooms for lockable drawers, there was no evidence that staff interviews were conducted as part of the investigation. The NHA confirmed that only residents were interviewed and staff were not questioned regarding the missing items. In the second case, another resident with intact cognition reported $280 missing from their room. The incident documentation did not indicate that an investigation was completed. Interviews with staff revealed that the resident had reported the missing money to a certified nursing assistant, who in turn reported it to the NHA and social worker. However, the NHA stated they had little knowledge of the allegation and confirmed that a thorough investigation, including interviews with other residents or staff, was not conducted. The facility's policy requires immediate and comprehensive investigation of such allegations, including interviews and documentation, which was not followed in these cases.
Failure to Document Resident's Self-Administration of Home Medications
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, specifically regarding medications brought from home and self-administered by the resident. Upon admission, the resident did not have access to all prescribed medications through the facility, leading the resident to request that their spouse bring pain medication and insulin from home. The resident independently administered these medications, but this was not documented in the medical record. Nursing progress notes lacked documentation of discussions about available medications, and there was no record of the physician being notified that the resident took their own medications due to the delay in pharmacy delivery. Interviews with staff revealed that the resident was offered insulin from the facility's supply but chose to use their own, and that the facility did not have the resident's narcotic medication available until a later pharmacy delivery. The Director of Nursing and LPNs involved confirmed that the administration of home medications was not fully documented in the electronic medical record. The facility's policy requires that all services provided, changes in condition, and resident responses be documented objectively and completely, which was not followed in this instance.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as evidenced by multiple staff not wearing required hair or beard restraints while in the kitchen and kitchenettes. Observations revealed that staff, including an activity aide, dietary aide, and cook, entered food preparation and service areas without appropriate hair coverings or beard restraints, contrary to both FDA Food Code requirements and the facility's own policies. Staff interviews confirmed a lack of understanding or adherence to these requirements, with some staff believing that hair restraints were unnecessary if their hair was tied back or if their beard was below a certain length, despite policy stating otherwise. Additionally, the facility did not ensure that the mechanical ware washing machine reached the required sanitizing temperatures. During observations, the ware washing machine failed to achieve the necessary 180 degrees Fahrenheit for the sanitizing cycle, and there was no evidence that alternative sanitization methods were consistently or properly used for dishes and utensils. Documentation reviewed for ware washing cycles did not reflect the actual temperatures observed, and there was no documentation that internal surface temperature strips were used to verify proper sanitization, as required by both FDA Food Code and facility policy. The facility also failed to properly test and document the use of quaternary sanitizing solution in the three-compartment sink. Staff did not test the water temperature when using the sanitizer, and used incorrect test strips to check the sanitizer's concentration. Manufacturer instructions for the sanitizer required testing at specific temperatures and with the correct test strips, but these procedures were not followed. The facility's logs did not include a place to document the temperature of the sanitizing compartment, and staff were observed using the sanitizer at temperatures far above the recommended range.
Failure to Complete Required Reference Checks for New CNAs
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy regarding employee screening for four Certified Nursing Assistants (CNAs). According to the facility's policy, all potential employees are required to undergo background, reference, and credentials checks, including attempts to obtain information from previous or current employers. However, upon review, the surveyor found that reference checks were not completed for any of the four CNAs reviewed. Documentation of reference checks was not provided for these employees, despite their recent hire dates. Interviews with facility staff, including the Nursing Home Administrator (NHA), Human Resources Assistant (HRA), and Director of Human Resources (DHR), confirmed that reference checks were not being conducted as part of the hiring process. The DHR acknowledged awareness of the policy requirement but stated that reference checks were not included in the onboarding package from the corporate office. The NHA indicated that the issue had been raised with corporate personnel but no changes had been made, and the policy continued to be disregarded.
Failure to Offer or Administer PCV20 Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered or administered to four residents, as required by current CDC guidelines. Specifically, the medical records for these residents showed that although they had previously received PPSV23 and PCV13 vaccines, there was no documentation that they were offered or administered the PCV20 vaccine. The residents involved had various medical conditions, including diabetes, respiratory failure, discitis, pleural effusion, asthma, ulcerative colitis, and myelopathy. All were of an age that made them eligible for the updated vaccination protocol, and none had documentation of refusal or contraindication for the PCV20 vaccine. During an interview, the facility's Infection Preventionist stated that it was their understanding that no further pneumococcal vaccinations were needed for these residents and acknowledged there was no system in place to offer the PCV20 vaccine. Upon review of the CDC guidelines presented by the surveyor, the Infection Preventionist confirmed the oversight and indicated a lack of awareness regarding the need to offer the PCV20 vaccine to eligible residents.
Failure to Provide Ordered Wound Care and Vital Sign Monitoring
Penalty
Summary
A resident with a right below-the-knee amputation (BKA), sepsis, gangrene, diabetes, hypertension, and a history of thyroidectomy was admitted to the facility and was responsible for their own healthcare decisions. The resident had a physician's order for specific wound care to the BKA site, including cleansing, application of Xeroform, ABD pad, Kerlix, and Ace or Coban wrap every evening shift every other day, and as needed. Despite this order, the resident reported that the surgical incision dressing had not been changed since admission, and the surveyor observed the dressing was dated several days prior. Documentation in the Treatment Administration Record (TAR) indicated dressing changes were completed on certain dates, but the resident and physical evidence contradicted this, and the Director of Nursing (DON) later confirmed that at least one dressing change was not completed as documented. Additionally, the facility's policy required daily vital sign monitoring for residents receiving skilled services. The resident expressed concern that their blood pressure was not being monitored, which was significant given their medical history. Review of the medical record showed no documentation of vital signs being obtained on at least one day, and the DON verified that vital signs were not monitored as required. Staff interviews revealed inconsistent understanding and implementation of the facility's policies regarding vital sign monitoring and wound care documentation.
Failure to Implement Fall Prevention Intervention for At-Risk Resident
Penalty
Summary
Staff failed to consistently implement a fall prevention intervention for a resident with a history of falls and multiple risk factors, including osteoarthritis, muscle weakness, unsteadiness, and cognitive impairment. The resident's care plan specifically required that the walker be kept within reach, following two recent unwitnessed falls where the resident sustained injuries. Despite this intervention being added to the care plan, observations on multiple occasions revealed that the walker was not within the resident's reach—once folded and propped against a bedside table on the opposite side of the bed, and another time placed in the bathroom out of sight. Interviews with staff, including a CNA, LPN, DON, and Rehabilitation Director, confirmed that the walker was not kept within reach as care planned. Staff expressed concerns about the resident's safety if the walker was accessible, given the resident's need for moderate assistance with transfers and ambulation. However, the care plan directive was not followed, and the DON was unaware of staff concerns regarding the intervention. The NHA confirmed the expectation that the walker should be within reach if specified in the care plan.
Failure to Timely Change PICC Line Dressings and Injection Caps
Penalty
Summary
Two residents who had peripherally inserted central catheter (PICC) lines did not receive proper care and treatment as required by their physician orders and facility policy. For one resident with multiple diagnoses including metabolic encephalopathy and endocarditis, the PICC line dressing and injection caps were observed to be dated from the admission date, indicating they had not been changed as ordered. The treatment administration record (TAR) showed the dressing and caps were marked as changed, but direct observation and staff interviews confirmed they were not changed according to the weekly schedule. The Director of Nursing verified that the dressing and injection caps had not been changed as required. Another resident with diagnoses including discitis, spinal stenosis, diabetes, and enterocolitis also had a PICC line with orders for weekly dressing and injection cap changes. The resident reported that these changes were supposed to occur on a specific day each week, but observation revealed the dressing and equipment were not changed on the scheduled day. The TAR indicated the change was completed, but the resident and subsequent observation confirmed the dressing and injection caps were not changed until the following day. Both cases demonstrate a failure to follow physician orders and facility policy regarding the care and maintenance of central lines.
Failure to Follow Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy for a resident with wounds requiring infection control measures. The policy required all team members to wear appropriate personal protective equipment (PPE), including gown and gloves, during high-contact care activities for residents with chronic wounds. Despite clear signage and a PPE cart at the resident's room, staff were observed providing care and transferring the resident without donning the required PPE. On two separate occasions, certified nursing assistants assisted the resident with peri-care and transferring to bed without wearing gowns or gloves. One CNA was unsure of the resident's EBP status and did not check the posted signage before providing care. The resident's medical record and care plan indicated the presence of chronic wounds and specified the need for EBP, including the use of gown and gloves during care activities. A licensed practical nurse confirmed the resident's wounds and the requirement for EBP. Additionally, a restorative aide admitted to not wearing a gown when re-entering the resident's room to provide assistance, despite being aware of the EBP requirement. The therapy program manager and nursing home administrator both confirmed that staff should follow PPE requirements for residents on EBP. These lapses in infection control practices were directly observed and confirmed through staff interviews and record review.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically verbal abuse, in accordance with section 1150B of the Act. On November 4, 2024, a Licensed Practical Nurse (LPN-C) was witnessed verbally abusing a resident (R1) in a common area. Despite the facility's policy requiring immediate reporting of such incidents to law enforcement, the verbal abuse was not reported to local authorities. The incident involved LPN-C yelling derogatory terms at R1, who was crying out for help. Multiple staff members, including a Certified Nursing Assistant (CNA-E), a Housekeeper (HK-D), and another LPN (LPN-F), witnessed the incident and noted LPN-C's abnormal behavior, which included yelling, slurred speech, and an unsteady gait, raising concerns about possible intoxication. R1, the resident involved, was receiving hospice services and had diagnoses of dementia, anxiety, and depression, with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The facility's failure to report the incident to law enforcement was confirmed by the Nursing Home Administrator (NHA-A), who acknowledged the incident as verbal abuse. The facility's policy, revised in September 2024, mandates the reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and law enforcement within specified time frames, which was not adhered to in this case.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with moderate cognitive impairment, who was receiving hospice services and had diagnoses including dementia, anxiety, and depression. On the morning of the incident, a Licensed Practical Nurse (LPN) was observed verbally abusing the resident in a common area, telling them to stop and calling them a fool. The resident was assisted away from the LPN, who subsequently left the facility and did not return. Although the staff responded to the incident, the investigation was incomplete. The investigation did not include interviews with the resident, other residents, or all staff on duty at the time, including a witness to the incident. Additionally, there was no notification to local law enforcement, and the resident's care plan was not reviewed or revised following the incident. The facility's Nursing Home Administrator indicated that abuse education was not initially provided, as it was considered an isolated incident, and the resident's Power of Attorney for Healthcare had advised against contacting law enforcement due to the resident's dementia. Furthermore, there was no documentation of staff education or notification to the resident's Power of Attorney and physician.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that prescribed medication was available and administered correctly for a resident. The resident had an order for heparin sodium injection to be administered subcutaneously every 8 hours for 14 days. However, the medication was not administered as ordered on several occasions, as indicated by blank spaces on the Medication Administration Record (MAR) and lack of corresponding progress notes. Interviews with the Director of Nursing (DON) and other staff revealed that the facility had heparin available in contingency, and nurses had access to it. Despite this, the medication was not administered at the scheduled times, and there was no documentation to explain the omissions. The DON confirmed that the nurses did not need permission to access contingency medication and that the pharmacy could provide STAT orders if necessary. The investigation also highlighted that the facility's Omnicell machine, which tracks medication usage, did not show any heparin being removed during the relevant period. This suggests that the medication was not administered despite being signed out on the MAR. The DON acknowledged that the medication errors were not identified or reported at the time, and there was no follow-up documentation or incident reports related to the missed doses.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during the provision of incontinence care for a resident. The CNA did not appropriately remove gloves and cleanse hands after providing perineal care. Specifically, the CNA wiped the resident's peri-rectal area with wipes and then proceeded to pull up the resident's clean incontinence brief and pants, assist with ambulation, and touch various items in the resident's room without removing gloves or performing hand hygiene. The CNA's actions were observed by a surveyor, who noted that the CNA touched the resident's gait belt, walker, recliner remote control, blanket, call light, tray table, television remote, bathroom doorknob, and placed a clean nightgown in a dresser drawer, all without removing gloves or cleansing hands. The CNA later removed gloves and left the resident's room without completing hand hygiene. The Director of Nursing confirmed that staff should not double glove and should perform hand hygiene after removing soiled gloves, indicating a failure to adhere to the facility's hand hygiene policy.
Failure to Implement Abuse Policy for Employee Background Checks
Penalty
Summary
The facility did not implement their abuse policy for three of eight employees reviewed for background checks. Specifically, a Registered Nurse (RN) did not have a background check completed within the last four years, and the facility was unable to provide background check information for a Dietary Manager (DM) and a Certified Nursing Assistant (CNA) who were contracted employees. The facility's policy requires pre-employment and other background and abuse registry checks as mandated by local, state, and federal regulations. However, the RN's background information was last updated in 2019, and no updated information was provided. Additionally, the facility failed to provide any background check information for the DM and CNA, both of whom were contracted staff members. The Interim Nursing Home Administrator (INHA) confirmed that the RN's background information was out of compliance, and although a reminder was sent to the RN to complete a new Background Information Disclosure (BID) form, it was not completed. The Nursing Home Administrator (NHA) also confirmed that the facility did not have the required background check information for the DM and CNA. These lapses indicate a failure to adhere to the facility's abuse policy and regulatory requirements for background checks, potentially compromising resident safety and care quality.
Failure to Notify Physician and Monitor Daily Weights
Penalty
Summary
The facility did not ensure appropriate care and treatment for a resident (R2) who experienced a low irregular heart rate and low blood pressure. On 5/1/24, R2's pulse was documented as 50 bpm and irregular, but staff did not notify a physician or take any documented action in response. Similarly, on 5/3/24, R2's blood pressure was recorded as 75/52, and again, no action was taken to notify a physician or address the low blood pressure. R2's family later requested that R2 be seen in the emergency room due to a decline in condition and refusal to eat, leading to R2 being admitted to the ICU for hypotension. The Director of Nursing confirmed that staff should have notified a physician or nurse practitioner of these changes in R2's condition. Additionally, the facility failed to follow physician orders for daily weights for R2, who had diagnoses including congestive heart failure and was at high risk for weight loss and malnutrition. Despite an order for daily weights from admission on 4/29/24, only one weight was documented on 5/3/24. A Registered Dietician assessment on 5/2/24 noted the lack of documented weights and recommended nutritional supplements due to poor appetite. The Director of Nursing verified that staff should have followed the physician's order for daily weights.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility did not ensure staff used a gait belt during transfers for four residents (R4, R5, R6, and R7) out of five sampled residents. R6's baseline care plan indicated the need for assistance with transfers, and the facility's practice was to use a gait belt. However, on 5/29/24, a Certified Nursing Assistant (CNA) transferred R6 from a recliner to a wheelchair without using a gait belt. Additionally, residents R4, R5, and R7 reported that staff did not consistently use a gait belt during transfers. The facility failed to provide a specific transfer policy when requested by the surveyor, only providing a general back safety policy. Observations and interviews revealed that staff did not follow the expected protocol for using gait belts during transfers. R6 was observed being assisted without a gait belt, and interviews with R4, R5, and R7 confirmed that staff often did not use gait belts. The Physical Therapist Assistant (PTA) and Licensed Practical Nurse (LPN) both stated that gait belts should be used for safety during transfers. The Director of Nursing (DON) also confirmed that staff are expected to use gait belts for all assisted transfers. Despite these expectations, the facility did not ensure compliance, leading to the identified deficiency.
Medication Administration Deficiencies
Penalty
Summary
The facility did not ensure the accurate administration of medication for three residents, leading to several deficiencies. One resident, admitted after a fall, had an order for oxycodone for pain management. However, the narcotic count sheet and medication administration record (MAR) did not match, and there was no follow-up documentation for the effectiveness of the medication. Additionally, the facility ran out of the resident's oxycodone, and staff accepted oxycodone brought from the resident's home, which is against the facility's policy. The resident's medical record showed discrepancies in the documentation of administered doses, and the staff involved confirmed the issues during interviews with the surveyor. Another resident, admitted with a history of lung cancer, COPD, and hypertension, did not receive four doses of prescribed medication because the medications were not available upon admission. The resident's medical record indicated that the evening doses of atorvastatin, mirtazapine, Singulair, and guaifenesin were not administered. An agency nurse confirmed that the medications were not delivered on the day of admission and that it was common for new admissions to face such issues. The facility's Director of Nursing (DON) explained the workflow for obtaining medications and acknowledged that agency nurses did not always have access to contingency medication. A third resident, admitted with multiple diagnoses including a transient cerebral ischemic attack and hypertension, did not receive two doses of prescribed medication because the medications were not available upon admission. The resident's MAR indicated that the evening and bedtime doses of pravastatin and Toprol XL were not administered. Interviews with the resident and staff confirmed the issues with medication administration during the initial days of admission. The DON and Assistant Director of Nursing (ADON) provided details about the medication ordering and delivery process, highlighting the challenges faced in ensuring timely medication availability for new admissions.
Improper Administration of Medication
Penalty
Summary
The facility did not ensure that a medication was administered for its intended use for one resident. The resident was prescribed Benadryl as needed for itching but requested and was administered Benadryl for reasons other than itching. The resident, who had intact cognition, was admitted to the facility following a fall and had multiple diagnoses including a fracture, type 2 diabetes, insomnia, and low back pain. On one occasion, the resident reported severe pain and was administered acetaminophen and Benadryl by an agency nurse. The nurse confirmed that the resident requested Benadryl to help sleep, not for itching, and administered it despite the resident not experiencing itching. The facility's Medication Administration policy indicates that medications should be administered for the condition for which they are prescribed. The Assistant Director of Nursing and the Director of Nursing both confirmed that the Benadryl should only have been administered for itching, as per the prescription. The incident highlights a failure to adhere to the prescribed use of medication, leading to the administration of Benadryl for an unapproved reason.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, or injury to the State Agency (SA) and local law enforcement for five residents. On multiple occasions, residents reported abuse or injuries, but the facility did not submit the required initial reports within the mandated 24-hour period. For instance, Resident 5 and Resident 6 reported abuse on 2/27/24, but the initial reports were not submitted until 3/4/24. Similarly, Resident 7 reported abuse with injury on 3/6/24, but the initial report was delayed until 3/7/24 at 1:48 PM. Resident 3's injury of unknown origin was discovered on 3/28/24, but the initial report was not timely, and the five-day investigation was delayed until 4/4/24. Resident 4 reported abuse on 2/25/24, but the facility failed to notify local law enforcement and delayed the report to the SA until 3/7/24. The facility's policy on Resident Abuse/Neglect/Exploitation and Reporting Requirements mandates that any suspicion of a crime against a resident must be reported to the local law enforcement agency and the state survey agency within specific timeframes. If the incident involves serious bodily injury, it must be reported within 2 hours, and all other incidents must be reported within 24 hours. The results of abuse investigations must be reported to the state survey agency within 5 working days. However, the facility did not adhere to these requirements, leading to delays in reporting and investigation. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that neither had access to the portal to submit Facility-Reported Incidents (FRIs) to the SA until 3/7/24. The DON was unaware of the ability to fax or email concerns, contributing to the delays. The NHA, who started at the facility on 3/4/24, acknowledged the untimely submission of FRIs. These administrative oversights and lack of timely reporting mechanisms resulted in the facility's failure to comply with regulatory requirements for reporting abuse, neglect, and injuries of unknown origin.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were thoroughly investigated for six residents. For two residents, allegations of abuse were reported, but the investigation did not include interviews with other residents or a thorough follow-up on concerns identified through staff interviews. Another resident reported an allegation involving a CNA, but the investigation lacked interviews with staff and other residents, and the CNA was not removed from resident care pending the investigation's outcome. Additionally, a resident had an unwitnessed injury, but the investigation did not summarize or identify the cause of the injury. Another resident reported rough and rude behavior by a CNA, but the investigation did not include interviews with other residents or additional staff, nor did it summarize the investigation or complete staff education. Lastly, a resident reported a serious allegation of sexual assault, but the investigation did not include interviews or assessments of other residents or a summary of the investigation.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility did not ensure that a resident was free from abuse, as evidenced by the failure to implement interventions after staff members voiced concerns regarding a CNA's interactions with residents. On 2/27/24, two residents reported allegations of abuse, and other staff members identified the CNA in question as being rude and unkind. Despite these concerns, the CNA continued to be scheduled for shifts without documented intervention or thorough investigation by the facility. The CNA was later implicated in an incident on 3/5/24, where a resident reported being thrown around in bed, resulting in bruising. The facility's Director of Nursing confirmed that verbal education was provided to the CNA, but no documentation was available to support this claim prior to the incident on 3/5/24. The facility's failure to act on staff concerns and properly investigate the CNA's behavior led to continued exposure of residents to potential abuse. The CNA was eventually terminated on 3/14/24 following the incident on 3/7/24. The report highlights the facility's lack of documentation and thorough investigation, which contributed to the deficiency in protecting residents from abuse.
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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