Oakwood Village East Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 5833 American Parkway, Madison, Wisconsin 53718
- CMS Provider Number
- 525692
- Inspections on file
- 18
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Oakwood Village East Health And Rehab Center during CMS and state inspections, most recent first.
A resident with a history of pressure ulcers and decreased mobility was inaccurately assessed as not at risk for pressure injuries, resulting in an inadequate care plan and delayed interventions. Staff inconsistently staged and documented wounds, failed to notify the MD promptly of wound deterioration and infection, and did not follow prescribed wound care orders or provide education on treatment refusals. These failures led to the development of multiple stage 3 or unstageable pressure injuries, including an infected wound.
A resident with a physician order specifying that their Foley catheter should not be manipulated or removed except by urology had the catheter removed by an RN after observing improper drainage and a wet bed. The RN, aware of the order, removed the catheter without first consulting a provider or urology, and only attempted contact after removal. Facility policy and physician orders requiring prior notification and authorization were not followed.
The facility failed to maintain an effective infection prevention and control program, as staff returned to work too soon after GI symptoms, illness tracking forms were incomplete, and infection surveillance documentation for two residents was inaccurate. Additionally, a CNA did not perform required hand hygiene during catheter care, despite facility policy. These deficiencies had the potential to impact all residents.
The facility did not report multiple allegations of abuse and neglect to the state agency as required. Incidents included a resident reporting rough handling and a bruise, another resident experiencing unwanted touching by an LPN, a CNA observing an RN yelling and acting aggressively toward a resident, and other cases of staff refusing care or being rough during care. Despite staff and management acknowledging these as reportable allegations, the facility failed to follow its own policy and regulatory requirements for timely reporting.
Multiple residents and their representatives reported concerns of abuse, neglect, and exploitation, including unwanted touching, rough handling, verbal abuse, and refusal to provide care. The facility did not conduct thorough investigations as required, failed to remove accused staff from resident care during investigations, and did not consistently collect statements or report allegations to the state agency. Residents involved had various medical and cognitive conditions, and the facility did not follow its own policies for investigating and responding to these serious concerns.
The facility did not complete required PASARR Level II screenings for four residents with major mental disorders who remained in the facility beyond the 30-day hospital discharge exemption period. Each resident was admitted with diagnoses such as major depressive disorder and prescribed psychotropic medications, but the necessary follow-up screenings were not performed due to lapses in staff responsibility and oversight.
A resident's advance directive indicating a preference for CPR was not accurately reflected in the electronic medical record, which instead listed a DNR order. Nursing staff confirmed that the resident's code status should match across all records, but the update was not made, resulting in conflicting documentation.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or review antibiotic administration among residents.
A resident's medical record did not contain documentation showing that education about the influenza vaccine was provided or that the resident consented to or declined the vaccine for the most recent season. The required declination form was only completed after surveyors requested it, indicating a lapse in timely documentation as required by facility policy.
The facility failed to maintain a sanitary environment for food service, affecting all residents. Observations showed garbage cans without lids near food prep areas, crumbs in utensil containers, and unclean kitchenettes. Staff did not follow proper food temperature procedures, and a Dietary Aide failed to change gloves or perform hand hygiene while handling food. These deficiencies indicate non-compliance with cleaning and infection control protocols.
The facility failed to manage a COVID-19 outbreak effectively, as it did not recognize a single positive case as an outbreak per CDC guidelines. This led to delayed notification of public health authorities and the Medical Director, and inconsistent documentation of symptoms and testing. The Infection Preventionist acknowledged that outbreak protocols, including masking and testing, should have started earlier, but the absence of the IP and reliance on other staff resulted in inadequate outbreak management.
The facility failed to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications. Four residents were identified as not having adequate monitoring or assessments for their medication use. The facility's staff, including the RN and DON, were interviewed regarding the monitoring of residents. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care.
The facility failed to follow its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for several residents with UTIs. Documentation of necessary tests and symptoms was often missing, and criteria for antibiotic use were not consistently met, as confirmed by the Infection Preventionist.
A resident was found with an expired medication on their nightstand, which was not listed in their current orders or care plan. The facility lacked a self-administration assessment for the resident and did not have a Self-Administration policy. The LPN and DON confirmed the medication should not have been in the resident's room, highlighting a lapse in medication management.
The facility failed to develop comprehensive care plans for two residents using psychotropic medications. One resident, with COPD, diabetes, depression, and anxiety, lacked a care plan addressing antidepressants and antianxiety medication. Another resident, with anxiety disorder and Multiple Sclerosis, also lacked a care plan for antidepressant use. The DON acknowledged the need for care plans and was unsure about non-pharmacological interventions. The facility's care plan policy was not provided.
Failure to Prevent and Treat Pressure Injuries According to Standards of Practice
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for the prevention and treatment of pressure injuries in a resident with a history of pressure ulcers and significant risk factors. The resident was inaccurately assessed as not at risk for pressure injury development upon admission, despite a documented history of pressure injuries and decreased mobility. This led to an insufficient care plan that did not adequately address the resident's risk factors or include robust interventions to prevent pressure injuries. The care plan was not updated in a timely manner as the resident's condition changed, and interventions to prevent worsening or new injuries were not implemented promptly. Staff inconsistently staged and documented the resident's wounds, failing to provide detailed descriptions of wound characteristics in weekly assessments. There were discrepancies in wound staging, with some wounds being down-staged contrary to standards of practice, and incomplete documentation regarding the extent of granulation and epithelial tissue. Additionally, wound assessments and documentation were sometimes kept outside the resident's official medical record, leading to gaps in continuity of care. The resident's wounds showed signs of deterioration and infection, but the medical doctor was not notified in a timely manner about these changes. The facility also failed to follow physician orders for wound care and did not provide the resident with information about the risks and benefits when he refused to wear offloading boots, which were prescribed for treatment. Staff did not consistently follow standards of practice during wound care procedures, and treatment orders were not always implemented as prescribed. As a result of these failures, the resident developed multiple stage 3 or unstageable pressure injuries, including an infected wound, which constituted a finding of Immediate Jeopardy.
Foley Catheter Removed Against Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a physician order specifying that their Foley catheter should not be manipulated, flushed, or exchanged, and that only urology should address any issues, had their catheter removed by a registered nurse. The nurse observed that the resident's bed was wet, the catheter was not draining properly, and only 3mL of fluid was present in the balloon upon aspiration. Despite being aware of the explicit order not to manipulate or remove the catheter and to contact urology for any issues, the nurse proceeded to remove the catheter without first consulting a provider or urology. The nurse attempted to contact the primary provider and urology only after the removal had already occurred. Interviews confirmed that the nurse was aware of the standing orders and the facility's policies requiring physician notification and authorization for significant changes in treatment, including catheter removal. The urology clinic confirmed that an afterhours contact was available and that the catheter should not have been removed by facility staff. The Director of Nursing acknowledged that the nurse did not consult with a provider prior to removal and that the event took place before the clinic opened. The facility's failure to follow physician orders and internal protocols led to the deficiency.
Deficient Infection Control Program and Incomplete Surveillance Documentation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in staff illness tracking, resident infection surveillance, and adherence to hand hygiene protocols. One staff member returned to work less than 48 hours after experiencing gastrointestinal symptoms, contrary to CDC guidelines and facility policy, which require exclusion from work for at least 48 hours after symptom resolution. Additionally, the staff illness line list used for infection surveillance was incomplete, with five staff members missing the date of last symptoms, making it difficult to determine appropriate return-to-work timing and to conduct accurate illness tracking. Resident infection surveillance was also found to be deficient. For two residents, the infection line list did not accurately reflect their symptoms or infection details. One resident with a urinary tract infection had missing or incorrect information on the line list, including the onset date, symptoms, and laboratory results, and the infection was not recorded in the appropriate month. Another resident's line list entry did not match the information documented on the McGeer Criteria checklist, with discrepancies in symptoms and infection criteria. These inaccuracies in documentation hindered the facility's ability to conduct effective infection surveillance. Furthermore, staff did not consistently perform appropriate hand hygiene during resident care. During an observation of catheter care, a certified nursing assistant changed gloves four times without performing hand hygiene between glove changes, despite facility policy and standard practice requiring hand hygiene before donning and after removing gloves. The staff member acknowledged the expectation for hand hygiene but did not adhere to it during the observed care. These failures in infection control practices had the potential to affect all residents in the facility.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by state and federal regulations. In five separate cases, allegations of abuse or neglect were either not reported at all or not reported in a timely manner. These included incidents involving unwanted touching by a staff member, verbal and mental abuse, rough handling during care, and refusal to provide care. In each case, the facility's own policy required immediate reporting to the state agency, but this was not followed. One resident with mild cognitive impairment, anxiety, and depression reported that a nurse threw a pill in her mouth and made a derogatory comment, and later reported that a CNA caused a bruise by being rough during care. Both incidents were documented as concerns but were not reported to the state agency as allegations of abuse. Another resident and her representative reported unwanted touching in the vaginal area by an LPN during a skin assessment, which made the resident uncomfortable and fearful. Despite the resident's request for a female caregiver and the clear policy on reporting such allegations, the incident was not reported to the state agency or law enforcement. Additional incidents included a CNA reporting that an RN yelled at a resident, pulled a blanket off without warning, and slammed doors, which was not reported as verbal or mental abuse. Another resident's representative reported that a staff member refused to assist with care, and a resident reported being handled roughly during evening care. In all these cases, staff and management acknowledged during interviews that these were allegations of abuse or neglect that should have been reported, but there was no evidence that the required reports were made to the state agency.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure thorough investigations of multiple allegations of abuse, neglect, and exploitation involving several residents. In several instances, residents or their representatives reported concerns through the facility's grievance process, including unwanted touching by staff, rough handling during care, verbal abuse, and refusal to provide care. Despite these reports, the facility did not conduct comprehensive investigations as required by its own policies. For example, when a resident and her representative reported that an LPN touched her in a private area after she requested a female caregiver, the facility did not remove the staff member from duty pending investigation, nor did it interview other staff or residents who may have had relevant information. Similarly, when a CNA reported that an RN yelled at a resident, pulled off her blanket, and slammed doors, the RN was not suspended, and no further staff or resident interviews were conducted. The facility's policy mandates immediate action to ensure resident safety, including suspension of accused staff and thorough investigation of all allegations, regardless of perceived severity. However, in the reviewed cases, staff members accused of abuse or neglect continued to work with residents during and after the incidents. In several cases, the facility did not collect written statements from witnesses or involved parties, nor did it report the allegations to the state agency as required. Staff interviews revealed uncertainty about what constitutes a thorough investigation, and there was a lack of documentation showing that the facility followed its own procedures for investigating and reporting abuse allegations. Residents involved in these incidents had varying degrees of cognitive impairment and medical complexity, including diagnoses such as mild cognitive impairment, anxiety, depression, chronic obstructive pulmonary disease, and need for assistance with personal care. The failure to investigate allegations thoroughly was consistent across multiple cases, including those involving physical, verbal, and potential sexual abuse, as well as neglect. The facility did not provide evidence of comprehensive investigations, did not consistently remove accused staff from resident care, and did not always report allegations to the appropriate authorities, as required by policy.
Failure to Complete PASARR Level II Screenings for Residents with Major Mental Disorders
Penalty
Summary
The facility failed to complete the required PASARR Level II (Preadmission Screening and Resident Review) screenings for four residents who were admitted with diagnoses of major mental disorders and prescribed psychotropic medications. Each of these residents was initially admitted under a hospital discharge exemption, which allows for a 30-day maximum stay without a Level II screening. However, all four residents remained in the facility beyond the 30-day exemption period, and there was no evidence that the necessary Level II screenings were completed as required by federal regulations and facility policy. For each resident, documentation showed that the Level I PASRR screens identified the presence of a major mental disorder and the use of psychotropic medications. Despite this, and the fact that their stays exceeded the 30-day exemption, the facility did not initiate or complete the Level II screening process. Interviews with social workers and the Assistant Nursing Home Administrator confirmed that the oversight occurred due to a change in staff responsibilities and a lack of follow-up to ensure the PASRR program was maintained during staff transitions. The deficiency was further substantiated by the facility's own policy, which mandates that all new admissions and readmissions be screened for mental disorders or intellectual disabilities per the PASRR process. The failure to complete the Level II screenings was acknowledged by staff during interviews, who indicated that the screenings should have been completed once it was clear the residents would remain in the facility beyond the permitted exemption period.
Failure to Update and Reconcile Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurate and up to date in the electronic medical record. Specifically, one resident's CPR preference form indicated a desire for full code status (to receive CPR), while the electronic medical record and physician orders reflected a DNR (Do Not Resuscitate) status. This discrepancy was identified during a review of the resident's records and confirmed through interviews with nursing staff, who acknowledged that the resident's code status should be consistent across all documentation. The facility's policy requires that information about advance directives be prominently displayed and updated in the medical record, and that changes be communicated to the interdisciplinary team and reflected in the care plan. Despite this, the resident's updated CPR preference was not entered into the electronic medical record, resulting in conflicting documentation. Staff interviews confirmed awareness of the need for consistency between the resident's expressed wishes and the medical record, but the necessary updates were not made at the time the new preference was obtained.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating a lack of oversight regarding antibiotic administration and stewardship within the facility. No specific residents or staff were mentioned in relation to this deficiency, and no details about individual medical histories or conditions were provided.
Failure to Document Influenza Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident's medical record included required documentation regarding influenza vaccination. Specifically, the record did not indicate that the resident or their representative was provided education about the benefits and potential side effects of the influenza immunization, nor did it document whether the resident received the vaccine, declined it, or had a medical contraindication. The facility's policy requires that all residents be offered the influenza vaccine annually and that any refusal be documented and placed in the resident's medical record. In this instance, a resident was admitted to the facility and had documentation of receiving the influenza vaccine in a previous season, but there was no record of vaccination or declination for the most recent influenza season. When surveyors requested documentation, the facility was unable to provide a signed and dated declination form until after the request was made, at which point the resident and staff completed the form. This indicates that the required documentation was not present in the medical record at the time of the surveyor's initial review.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 36 residents. Observations revealed that garbage cans in the kitchenettes and main kitchen lacked lids and were placed near food preparation areas. Additionally, containers holding spatulas and spoons contained crumbs and dried substances. The kitchenettes on the first and second floors had crumbs and dust inside cupboards, and the microwave on the first floor had dried food inside. These conditions indicate a lack of adherence to cleaning protocols, despite management providing cleaning checklists and staff meeting notes outlining cleaning expectations. The facility's staff did not follow proper procedures for taking food temperatures. An Executive Chef was observed using a thermometer incorrectly by placing it in a liquid sanitizer without properly drying it before using it on another food item. The chef also failed to use alcohol wipes as recommended by the facility's policy. This improper practice was acknowledged by the Director of Culinary Services, who indicated that education would be provided to staff regarding the correct procedures. Hand hygiene and glove use were also inadequate. A Dietary Aide was observed handling food and touching various surfaces in the kitchenette without changing gloves or performing hand hygiene. This included touching meal tickets, microwave, plates, and other items before returning to serve food. The Dietary Aide admitted to not changing gloves as required, despite having been educated on proper glove use during orientation. This failure to adhere to infection control policies poses a risk of cross-contamination and highlights a need for improved compliance with hand hygiene standards.
Inadequate COVID-19 Outbreak Management
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which led to a deficiency in managing a COVID-19 outbreak. The outbreak began when an occupational therapist tested positive for COVID-19, but the facility did not recognize this as an outbreak according to CDC guidelines, which define an outbreak as a single new case of COVID-19 among residents or staff. Consequently, the facility did not notify public health authorities, the Medical Director, or the community in a timely manner, nor did it implement outbreak protocols such as masking and testing immediately. The facility's documentation was inconsistent and incomplete, as evidenced by multiple line lists with differing symptomology for staff members. This inconsistency made it difficult to determine the correct symptomology used for outbreak surveillance and tracking. Additionally, the facility failed to document COVID-19 testing in the resident medical records or staff files, further complicating the tracking and management of the outbreak. The Infection Preventionist (IP) admitted that the outbreak should have been declared earlier and that testing and masking should have started with the first positive case. However, due to the IP's absence on vacation, the outbreak management was left to a medical assistant and supervisors, leading to a lack of proper notification and documentation. The facility's failure to follow CDC recommendations and maintain accurate records contributed to the ineffective management of the COVID-19 outbreak.
Failure to Monitor Residents on Psychogenic Medications
Penalty
Summary
The facility failed to ensure that residents were appropriately monitored and assessed for the use of psychotropic medications. Four residents were identified as not having adequate monitoring or assessments for their medication use. Specifically, one resident was receiving psychogenic medication without adequate monitoring, and another was not receiving proper assessment for their medication. Additionally, the facility did not have a policy in place for sleep assessments, and one resident was not receiving the necessary assessment for their medication. The facility's staff, including the RN and DON, were interviewed regarding the monitoring of residents. The RN reported that they were monitoring for specific conditions, but the facility did not have a policy in place for sleep assessments. The DON reported that they were not sure if the residents were being monitored for side effects, and the facility did not have a policy in place for sleep assessments. The facility's staff were not adequately monitoring the residents, and the facility did not have a policy in place for sleep assessments. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care. The facility's staff were not adequately monitoring the residents, and the facility did not have a policy in place for sleep assessments. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care.
Inappropriate Antibiotic Use Due to Non-Adherence to Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) by not ensuring appropriate antibiotic use protocols and monitoring systems were followed for several residents. Specifically, five residents were prescribed antibiotics for urinary tract infections (UTIs) without appropriate indications. The facility's policy requires the use of McGeers and/or Loeb Minimum Criteria to determine the necessity of antibiotic treatment, but this was not consistently applied. For Resident 9, the facility's infection control log indicated a UTI with symptoms of mood swings and irritability, but there was no documentation of a urinalysis (UA) or culture and susceptibility (C&S) to support the antibiotic prescription. Similarly, Resident 23 was prescribed antibiotics despite the absence of documented symptoms and criteria not being met, as confirmed by the Infection Preventionist (IP). Resident 4 was also on antibiotics without documented symptoms or justification, and the prescribed antibiotic was not on the susceptibility list for the identified pathogen. Resident 5 was treated with antibiotics for a UTI, but the facility could not provide the necessary UA and C&S documentation. Lastly, Resident 291 was prescribed antibiotics without documented symptoms or pathogen information, and the IP confirmed that the resident should not have been on antibiotics. These deficiencies highlight a lack of adherence to the facility's ASP and infection control policies, resulting in inappropriate antibiotic use.
Failure to Ensure Appropriate Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for a resident, identified as R10, who was part of a sample of 12 residents. The surveyor observed a medication bottle on R10's nightstand, which R10 identified as an as-needed medication. However, there was no self-administration assessment on file for R10, and the medication was not listed in R10's current orders or care plan. The medication was also expired, and the resident was unable to recall if an assessment had been completed. Further investigation revealed that the facility did not have a Self-Administration policy in place. Interviews with the LPN and the DON confirmed that R10 did not have a self-administration assessment and that the medication should not have been in R10's room. The LPN was unaware of the medication and confirmed it was not ordered for R10, indicating a lapse in medication management and oversight by the facility.
Deficiency in Care Planning for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents regarding their use of psychotropic medications. Resident 11, who was admitted with diagnoses including COPD, Type 2 Diabetes Mellitus, depression, and anxiety, was taking antidepressants buspirone and sertraline daily, as well as the antianxiety medication lorazepam on an as-needed basis. However, the care plan for Resident 11 did not address the use of these medications, the side effects to monitor for, or any non-pharmacological interventions to assist with managing depression or anxiety. Similarly, Resident 32, admitted with generalized anxiety disorder, Multiple Sclerosis, and status-post abdominal surgery, was taking the antidepressant sertraline daily. The care plan for Resident 32 also lacked details on the use of the medication, side effects to monitor, and non-pharmacological interventions for anxiety. During an interview, the Director of Nursing acknowledged that psychotropic medications should be addressed in care plans and expressed uncertainty about the non-pharmacological interventions in place for residents with depression and anxiety. The facility's care plan policy was requested but not provided.
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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