Oconto Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oconto, Wisconsin.
- Location
- 101 First St, Oconto, Wisconsin 54153
- CMS Provider Number
- 525670
- Inspections on file
- 31
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Oconto Health And Rehab Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions reported that a CNA told them they could not be assisted out of bed into a wheelchair if they only wanted to be up for a short period, and this concern was documented as a grievance and reviewed by the DON. The same resident also disclosed giving a tumbler as a gift to the CNA, despite knowing gifts to staff were not allowed, and the CNA ultimately accepted the gift after initially refusing. Although the facility’s abuse, neglect, and exploitation policy required timely reporting of all alleged violations to the State Agency, the NHA and DON acknowledged that these allegations of abuse and exploitation were not reported as required.
A resident with intact cognition and multiple medical conditions reported that a CNA told them they could not get out of bed if they only wanted to be up in a wheelchair for a short period, and also reported having given a tumbler as a gift to the same CNA. The DON documented the grievance as the resident changing their mind about getting up and confirmed that the CNA initially refused but ultimately accepted the gift before returning it. However, the facility did not remove the CNA from resident care during the inquiry, nor did it interview other residents or staff to determine whether similar incidents or additional gift exchanges had occurred, and leadership later acknowledged the investigations were not sufficiently thorough.
Surveyors found that staff did not consistently clean or document cleaning of CPAP/BiPAP/AVAP equipment as ordered and per facility policy for three cognitively intact residents using respiratory support devices. One resident with obstructive sleep apnea and paraplegia had a daily AVAP mask cleaning order, but the treatment record lacked the cleaning order on a key date, and the resident reported mask cleaning was not done and later developed facial cellulitis. Another resident with obesity and obstructive sleep apnea had weekly CPAP cleaning orders but reported the mask was washed only once since admission, and the treatment record showed missed cleanings marked with a code requiring nursing notes that were not present. A third resident with acute and chronic respiratory failure had a daily BiPAP mask cleaning order, was unsure if cleaning occurred, and had at least one day without documented cleaning. An LPN stated nurses were responsible for cleaning and documenting, and the DON confirmed the expected daily mask and weekly tubing cleaning and acknowledged missing documentation.
A resident with facial cellulitis and intact cognition was prescribed oral clindamycin TID after an ER visit, but the facility failed to administer five ordered doses because the medication was not available from the pharmacy and was not in contingency stock. The MAR documented three missed doses on one day and two the next, with the first dose given later that second day. The physician was not notified of the missed doses. During this time, the resident’s facial cellulitis became more painful, leading to repeated hospital transfers where an MRSA cheek abscess with preseptal cellulitis was diagnosed and treated with irrigation, debridement, IV antibiotics, wound packing, and additional oral antibiotics.
A resident with a history of dementia and other conditions experienced a worsening skin condition in the groin area, but the facility failed to notify the physician of this change. Despite documentation of care interventions, the lack of communication with the physician was a deficiency in the facility's protocol.
A resident's grievance regarding cleanliness, roommate issues, and shower frequency was not properly documented or resolved by the facility. The resident's guardian reported these concerns, but the facility failed to communicate the investigation's findings or any corrective actions taken. Despite some improvements, the guardian was not informed of interventions to prevent future issues.
A resident with a history of stroke and other conditions reported that a CNA twisted their wrist, causing pain. The incident was reported to staff and the resident's POAHC, but the facility failed to report the allegation to the State Agency or law enforcement as required by their policy. Interviews revealed that staff did not recall or act on the report, leading to a deficiency in reporting the abuse allegation.
A resident reported an allegation of physical abuse by a CNA, which was also communicated to the resident's POAHC and facility staff. However, the facility failed to conduct a thorough investigation as required by their policy, including obtaining statements from involved parties and documenting the incident. The NHA and DON were unaware of the allegation, indicating a deficiency in the facility's response to abuse reports.
Two residents received personal care from an unqualified Hospitality Aide (HA) who was not trained or certified to perform such tasks. The HA assisted with showering, feeding, and transferring, which was outside their job scope. The facility's administration was unaware of these actions.
A resident with an indwelling catheter and wounds did not receive proper infection control measures as CNAs and an RN failed to wear gowns and perform hand hygiene during care. The facility's policy on Enhanced Barrier Precautions was not followed, and gowns were not available near the resident's room. Staff interviews confirmed the oversight.
A resident with moderately impaired cognition refused multiple medications over several days, but the facility failed to notify the resident's physician and corporate Guardian as required by their policy. The medications included those for heart health, hypertension, OCD, depression, and diabetes. The resident's Guardian was unaware of these refusals, and the Director of Nursing acknowledged that staff should have contacted the physician after three refusals.
Two residents in an LTC facility experienced deficiencies in nutritional and hydration care. One resident, with multiple diagnoses, did not have their diet order updated despite a recommendation, leading to weight loss. Another resident, at risk for dehydration, had inconsistent fluid intake documentation. The facility failed to adhere to its policies on nutritional management and hydration monitoring.
Two residents in the facility did not receive their prescribed medications correctly. One resident did not receive calcium 200 mg due to unavailability, and the LPN failed to notify the physician. Another resident received the wrong form of Seroquel XR 50 mg, as the LPN administered a non-extended release version from contingency stock without physician consultation. These actions were against the facility's Medication Administration Policy.
A resident with impaired cognition and a corporate guardian was unable to set up a petty cash fund or RFMS account due to the facility's requirement for direct deposit information, which the guardian could not provide. The facility returned checks sent for the resident, and interviews revealed a lack of process for managing petty cash accounts without direct deposit. The resident expressed a desire for financial independence, but the facility did not accommodate this need.
A resident with a history of diabetes, right hand amputation, and hemiplegia was found with a contracted left hand containing a washcloth, but their care plan lacked interventions to address the contracture. The Nursing Home Administrator confirmed the oversight, and a Hospice RN reported cleaning green slime from the hand. Despite these issues, the care plan remained inadequate, leading to a deficiency.
A resident with significant medical conditions, including diabetes and hemiplegia, experienced a 14.71% weight loss due to the facility's failure to consistently monitor and document nutrition and hydration intake. The resident required one-on-one feeding assistance, but staff did not consistently document meal and fluid intake, and the care plan lacked an intervention for hourly water provision. The facility's limited education efforts and reliance on agency CNAs contributed to the deficiency.
A resident with Huntington's disease and moderate cognitive impairment repeatedly exited the facility unsupervised, posing significant safety risks. The facility failed to implement effective monitoring and intervention strategies, resulting in multiple incidents where the resident was found by police walking on highways and country roads. Despite the resident's refusal to wear a Wanderguard, the facility did not adequately assess or address the resident's risk for elopement.
A resident with Huntington's disease and a history of suicide attempts did not receive appropriate psychiatric follow-up or expedited guardianship at a facility. Despite repeated elopements and unsafe behavior, the facility failed to reassess the resident's needs or make necessary referrals, leading to multiple incidents where the resident was found in dangerous situations. Interviews revealed a lack of timely action and communication regarding the resident's safety and psychiatric needs.
The facility did not implement its abuse policy properly, as it failed to complete an out-of-state background check for the DON and had an incomplete BID form for a Laundry Aide. The BOM, new to the HR role, acknowledged these oversights.
A survey identified multiple infection control deficiencies in an LTC facility, including incomplete infection surveillance records, inadequate hand hygiene by a CNA during resident care, improper storage and use of medical supplies in a resident's room, and failure by an LPN to sanitize a blood pressure cuff between residents. The DON acknowledged these issues, which affected the facility's ability to prevent the transmission of infections.
A resident was observed with medications at their bedside without an accurate self-administration assessment or physician's order reflecting the allowed medications. The care plan lacked details on medication storage, and discrepancies were found between the physician's orders and the medications being self-administered. The resident, with intact cognition, was responsible for their healthcare decisions but was not correctly assessed for self-administration capabilities.
A resident with PTSD, anxiety, and depression was admitted to a facility without a proper PASRR Level II Screen due to an inaccurate Level I Screen. The oversight was confirmed by the facility's MDS coordinator and DON, who acknowledged that the resident's mental health diagnoses should have triggered a Level II Screen.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan did not reflect the need for bed rails, despite the resident's request and the facility's policy requiring a person-centered approach. Another resident's care plan did not include a preference for caregivers of the same gender, despite a history of sexual assault. The Director of Nursing confirmed that these individualized interventions should have been included.
A resident with severe cognitive impairment did not receive routine nail care as required by the facility's policy. Observations revealed the resident's toenails were overgrown and causing discomfort. Staff interviews indicated inconsistencies in nail care practices, with records showing the resident's nails had not been trimmed since admission.
The facility failed to maintain accurate documentation for two residents regarding the use of assistive devices. One resident's care plan did not reflect the use of bed rails, and assessments were not documented. Another resident's cane was removed without proper documentation of the incident or discussion. These deficiencies were identified through observations and interviews, highlighting gaps in the facility's compliance with medical record-keeping standards.
The facility failed to ensure that call lights were within reach for three residents, including one with cerebral infarction and another with chronic pain syndrome. Observations revealed that call lights were either placed out of reach or obstructed, preventing residents from notifying staff for assistance.
A facility failed to administer hydrocortisone to a resident with a history of cerebral infarction and anxiety disorder due to an unaddressed allergy concern, delaying the medication despite physician orders. Additionally, a nurse improperly disposed of a half tablet of buspirone in the garbage instead of using a Drugbuster, as per facility policy, during medication administration for a resident with bipolar disorder.
The facility failed to document, investigate, or resolve grievances for two residents who reported issues with a CNA. One resident was not changed from the previous day, and another was left wet and ignored. The facility did not follow its policy for prompt grievance resolution, and the concerns were not properly documented or investigated.
Failure to Report Allegations of Abuse and Exploitation to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and exploitation to the State Agency as required by its Abuse, Neglect and Exploitation policy. The policy, revised 7/1/25, required reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other allegations. A cognitively intact resident, with a BIMS score of 14/15 and diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression, filed a grievance on 2/6/26 stating that a CNA told the resident they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The DON confirmed the resident had reported that the CNA refused to get the resident into the wheelchair during an overnight shift if the resident only wanted to be up for an hour, and that the CNA later stated they had told the resident they might not be able to return in an hour due to assisting other residents. This allegation of abuse was not reported to the State Agency. The facility also did not report an allegation of exploitation involving the same resident and the same CNA. A progress note by the social worker designee documented that the resident had spoken with attorneys and was advised to inform the facility that the resident had given the CNA a tumbler as a gift, and that the resident knew they were not supposed to give gifts to staff. The DON stated that the resident had informed her that the resident purchased a mug for the CNA, who initially refused it multiple times but eventually accepted it due to pressure from the resident. During interviews, both the NHA and DON confirmed that allegations of exploitation should be reported to the State Agency, but this allegation was not reported, resulting in a failure to follow the facility’s own reporting procedures for abuse and exploitation.
Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and exploitation involving one cognitively intact resident, R4. R4, who had diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression and a BIMS score of 14/15, filed a grievance stating that a CNA told R4 they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The grievance, reviewed by the DON, was summarized as R4 requesting to get up but changing their mind due to the length of time they would need to remain in the wheelchair, and staff were noted as having been educated on residents’ rights to choose when to be out of bed. However, the facility did not interview other residents or staff to determine if similar incidents had occurred, and the CNA involved was not removed from resident care during the investigation. The NHA and DON later acknowledged that a more thorough investigation of this abuse allegation should have been completed. The facility also did not fully investigate an allegation of potential exploitation when R4 reported having purchased and given a tumbler/mug as a gift to the same CNA. R4 told the social worker designee that attorneys had advised R4 to inform the facility about the gift and acknowledged knowing residents were not supposed to give gifts to staff. The DON confirmed that R4 reported buying a mug for the CNA, that the CNA initially refused it multiple times but ultimately accepted it due to pressure from R4, and that the mug was later returned. Although the facility had documentation that staff were educated on not accepting gifts from residents, there was no evidence that other residents or staff were interviewed to determine whether other gifts had been given and accepted. The NHA and DON agreed that the allegation of exploitation was not investigated thoroughly.
Failure to Clean and Document CPAP/BiPAP/AVAP Equipment per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure CPAP/BiPAP/AVAP equipment was cleaned according to physician orders and the facility’s CPAP/BiPAP Cleaning policy for three residents using respiratory support devices. The policy, revised 6/11/25, required daily cleaning of mask frames after use with CPAP cleaning wipes or soap and water, with proper drying and storage, in accordance with CDC guidelines and manufacturer recommendations. For one resident with paraplegia and obstructive sleep apnea, the medical record showed an AVAP order to clean the mask daily starting 12/14/23, but the December 2025 Treatment Administration Record (TAR) did not contain an order to clean the AVAP mask on 12/4/25. This resident, who was cognitively intact and responsible for their own healthcare decisions, reported that lack of AVAP mask cleaning, along with staff popping a pimple, started irritation on the face, and was diagnosed with facial cellulitis on 12/15/25. A second resident with obesity and obstructive sleep apnea had an order to clean the CPAP mask, headgear, and tubing with mild soap and warm water each morning every Friday for sleep apnea care, starting 12/14/24. This resident, also cognitively intact and responsible for their own healthcare decisions, reported the CPAP mask had been washed only once since admission. The March 2026 TAR showed CPAP cleaning entries marked with a “4” on two dates, indicating a nursing progress note should explain why the treatment was not completed, but no such progress notes were found in the medical record, as confirmed by the DON. A third resident with acute and chronic respiratory failure with hypoxia and an activated POA for healthcare had an order to clean the BiPAP mask once daily starting 2/14/26; this resident was unsure if staff cleaned the mask daily, and the March 2026 TAR lacked documentation of BiPAP cleaning on one date. An LPN stated nurses were responsible for cleaning CPAP/BiPAP/AVAP masks and documenting this in the TAR, and the DON confirmed that masks should be cleaned daily, tubing weekly, and that there were missing dates of completion for all three residents.
Failure to Administer Ordered Antibiotic and Notify Physician of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident, who was cognitively intact and responsible for their own healthcare decisions, had a history of left cheek cellulitis. On 12/15/25, nursing documentation described a 4–5 cm swollen, hard, red, warm, and painful area on the resident’s left upper cheek, with a small open center and increasing size and pain over at least three days. The nurse noted there were no prior requests to the physician for advisement, and the resident ultimately requested transfer to the ER that evening. The hospital diagnosed facial cellulitis and prescribed clindamycin 300 mg by mouth three times daily starting 12/16/25. Upon return to the facility, the clindamycin order was not carried out as written due to medication unavailability from the pharmacy. The Medication Administration Record showed that three doses on 12/16/25 and two doses on 12/17/25 were not administered, with the first documented dose given on the PM shift of 12/17/25. The facility did not notify the physician about the missed doses. During this period, the resident’s cellulitis became more painful, leading the resident to request hospital transfer again on 12/17/25 and then again on 12/20/25. Subsequent hospital records documented a MRSA left cheek abscess with preseptal cellulitis requiring irrigation, debridement, wound packing, IV vancomycin, and continued wound care and oral antibiotics after discharge. The DON confirmed that clindamycin was not available in contingency stock, the pharmacy did not deliver it timely, and that the resident missed a total of five doses between 12/16/25 and 12/17/25.
Failure to Notify Physician of Resident's Worsening Skin Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident, identified as R7, who was experiencing a worsening skin condition. R7, who had a history of dementia, epilepsy, schizophrenia, anxiety, and traumatic brain injury, was admitted with a moderately impaired cognitive status. The resident's skin condition, specifically redness and pain in the groin and scrotum area, was noted to have worsened over time. Despite this change, the facility did not update R7's physician about the deterioration of the skin condition, which was a requirement according to the facility's Notification of Changes policy. The issue was identified during a survey when the Nursing Home Administrator (NHA) acknowledged that the physician should have been informed of the change in R7's skin condition. Documentation showed that an antifungal powder was ordered for R7's groin area, and the care plan was updated to allow R7 to wash their own peri area. However, the lack of communication with the physician regarding the worsening condition from December to February was a deficiency in the facility's protocol for notifying changes in a resident's condition.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure a grievance was documented, thoroughly investigated, and resolved for a resident, identified as R18, who was part of a sample of 19 residents. The grievance was submitted by R18's court-appointed guardian, GDN-I, who raised concerns about cleanliness, R18's roommate, and the frequency of showers. The grievance form indicated that follow-up occurred the day after the grievance was submitted, but GDN-I reported not being updated on all components of the grievance or how it was resolved. The facility's grievance policy requires that grievances be recorded, logged, and resolved with the resident or their representative being kept informed of the progress. The surveyor's review of the grievance log and interviews with GDN-I and the Nursing Home Administrator (NHA-A) revealed discrepancies in the documentation and communication of the grievance resolution. GDN-I noted that R18 had food on their clothing and surrounding areas, had not received a shower for over a week, and had an inappropriate roommate. Although some actions were taken, such as a room change and scheduling showers, GDN-I was not informed of the investigation's findings or any interventions to prevent future occurrences. NHA-A considered the initial conversation with GDN-I as follow-up but did not provide further documentation or resolution details, leading to the deficiency finding.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R1, to the State Agency as required by their policy. R1, who had a history of cerebrovascular accident, left hemiparesis, dysphagia, and diabetes, reported that a Certified Nursing Assistant (CNA-E) had grabbed and twisted R1's right wrist, causing pain. This incident was reported by R1 to an unidentified staff member and R1's Power of Attorney for Healthcare (POAHC). However, the allegation was not communicated to the State Agency or local law enforcement, as confirmed by the Nursing Home Administrator and Director of Nursing during the survey. The facility's policy mandates immediate investigation and reporting of abuse allegations to the appropriate authorities within specified time frames, particularly within two hours if the allegation involves abuse or results in serious bodily injury. Despite this, the survey revealed that the allegation, which was initially reported during the summer of 2024, was not followed up on, and the POAHC did not receive any updates regarding the investigation. Interviews with staff, including RN-G, who was informed of the incident, showed a lack of recall or action taken, contributing to the deficiency in reporting the abuse allegation as required.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R1, who reported that a Certified Nursing Assistant (CNA-E) had grabbed and twisted their right wrist, causing pain. This incident was reported by R1 and their Power of Attorney for Healthcare (POAHC-J) to the facility staff, including a Registered Nurse (RN-G) and a Licensed Practical Nurse (LPN-H). However, the facility did not conduct a comprehensive investigation as required by their Abuse, Neglect, and Exploitation policy. The policy mandates immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, interviewing all involved parties, and documenting the investigation thoroughly. Despite the report of abuse, the facility did not obtain statements from R1, CNA-E, or other potential witnesses, and there was no follow-up with POAHC-J regarding the allegation. During the survey, the Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) indicated they were unaware of the allegation. The lack of a thorough investigation and documentation of the incident represents a deficiency in the facility's handling of abuse allegations, as outlined in their policy.
Unqualified Staff Performing Personal Care Tasks
Penalty
Summary
The facility failed to ensure that showers, feeding assistance, and activities of daily living (ADLs) were performed by a qualified person for two residents. Hospitality Aide (HA)-D, who was not a Certified Nursing Assistant (CNA) and had not received the necessary training or competency assessments, assisted residents with personal care tasks such as showering, feeding, and transferring. This was outside the scope of HA-D's job responsibilities, which were limited to providing basic assistance without hands-on care. Resident 15 and Resident 19 were directly affected by this deficiency. Resident 15, who was not cognitively impaired, reported that HA-D completed personal care tasks such as showering and dressing. Similarly, Resident 19, who had a traumatic spinal cord injury with paraplegia and other medical conditions, indicated that HA-D assisted with showering, dressing, and transferring using a Hoyer lift. The Nursing Home Administrator and Director of Nursing were unaware of HA-D's involvement in feeding residents and confirmed that such tasks were beyond HA-D's scope of practice.
Inadequate Infection Control Practices for Resident with Catheter and Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of Enhanced Barrier Precautions (EBP) and hand hygiene practices for a resident with an indwelling catheter and wounds. On March 11, 2025, Certified Nursing Assistants (CNAs) E and F did not wear gowns while providing personal hygiene and catheter care to the resident, despite the facility's policy requiring gown use during high-contact resident care. Additionally, Registered Nurse (RN) G did not wear a gown or perform hand hygiene between glove changes during wound care for the same resident. The resident, who was not cognitively impaired, had multiple diagnoses including quadriplegia, diabetes, polyneuropathy, and a pressure ulcer, and was on EBP due to an indwelling urinary catheter, ostomy, and wounds. The surveyor observed that there were no gowns available near the resident's room, contrary to the facility's policy. Interviews with the CNAs, RN, Director of Nursing, and Nursing Home Administrator confirmed the failure to adhere to the infection control protocols, acknowledging that gowns should have been worn and hand hygiene should have been performed between glove changes.
Failure to Notify Physician and Guardian of Medication Refusals
Penalty
Summary
The facility failed to notify a physician and a corporate Guardian about a resident's repeated medication refusals, which is a violation of their Medication Administration policy. The policy requires physician notification if two consecutive doses of a vital medication are withheld or refused. The resident, who has moderately impaired cognition and a corporate Guardian for decision-making, refused multiple medications on several occasions in January and February 2025. These medications included those for heart health, hypertension, OCD, depression, personality disorder, GERD, and diabetes mellitus type 2. Despite these refusals, there was no documentation of physician or Guardian notification in the resident's medical record. Interviews conducted by the surveyor revealed that the resident's Guardian was unaware of the medication refusals and that these refusals were not discussed during a care conference. The Director of Nursing confirmed that staff should have contacted the resident's physician after three medication refusals, indicating a lapse in following the facility's policy. This oversight in communication and documentation led to the deficiency identified by the surveyors.
Deficiencies in Nutritional and Hydration Care for Two Residents
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for two residents, R3 and R1, leading to deficiencies in maintaining their health. R3, who had multiple diagnoses including dysphagia and moderate intellectual disability, was on a mechanical soft diet with ground meat. Despite a recommendation from Speech Therapy to upgrade R3's diet to cut-up meat, the diet order was not changed, and a swallow study was not completed. Additionally, R3's meal intakes were inconsistently documented, contributing to a 7.3% weight loss over three months. R3's guardian and family were not informed about the dietary restrictions, and there was a lack of communication and follow-up regarding the necessary dietary adjustments. R1, who had conditions including diabetes and hemiplegia, was at risk for dehydration and required total assistance with eating. The facility's staff did not consistently document or monitor R1's fluid intake, with 56.78% of shifts missing documentation. Although staff were observed offering fluids to R1, the lack of documentation made it unclear whether R1 was receiving adequate hydration. The Director of Nursing acknowledged the missing documentation and the expectation for CNAs to record fluid intake every shift. The facility's policies on nutritional management and hydration monitoring were not adhered to, resulting in inadequate care for R3 and R1. The failure to update R3's diet order and complete a swallow study, along with the inconsistent documentation of meal and fluid intake, highlighted significant lapses in the facility's care processes. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyor.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, R5 and R6, as observed during a survey. R5 did not receive the prescribed calcium 200 mg during the morning medication pass because the medication was unavailable in the facility. The Licensed Practical Nurse (LPN) responsible for administering the medication did not notify R5's physician about the missed dose, which was against the facility's Medication Administration Policy. R5 had multiple diagnoses, including a disorder of bone and chronic systolic heart failure, which necessitated the calcium supplement. R6, who had diagnoses including schizoaffective disorder and COPD, did not receive the correct form of Seroquel XR 50 mg as ordered. Instead, the LPN administered two 25 mg tablets of quetiapine, which was not the extended-release form required. This substitution was made from the facility's contingency stock without consulting the physician, resulting in a medication error. The Director of Nursing confirmed that the LPN administered an incorrect medication to R6, which was a deviation from the prescribed treatment plan.
Failure to Establish Resident Financial Account
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs by not allowing a resident, who had a corporate guardian, to set up a petty cash fund or Resident Fund Management Service (RFMS) account. The resident, identified as R2, was admitted with diagnoses including dementia, schizophrenia, and anxiety, and had a severely impaired cognition score. Despite requests from R2's corporate guardian to establish a resident account, the facility required direct deposit account information, which the guardian could not provide due to organizational restrictions. As a result, the facility returned two checks sent by the guardian for R2, as the RFMS authorization agreement was not signed. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) revealed that the facility did not have a process to manage petty cash accounts without a direct deposit setup. The BOM indicated that it was not the facility's responsibility to manage residents' finances without legal authority, and the NHA confirmed that the facility should handle funds if requested by residents. The resident expressed a desire to have access to money to make purchases like other residents but was unsure how to establish an account. The facility's inability to accommodate the resident's financial management needs led to the deficiency.
Failure to Address Resident's Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care to prevent further decrease in range of motion for a resident with a contracted left hand. The resident, who had a history of diabetes mellitus, right hand amputation, and hemiplegia following a stroke, was observed with a contracted left hand containing a rolled-up washcloth. The resident's care plan did not include interventions to address the contracture, which was confirmed by the Nursing Home Administrator. The administrator acknowledged that the care plan should have included measures to prevent the worsening of the contracture and mentioned that therapy staff were in the process of finding a suitable piece of foam for the resident's hand. Additionally, a Hospice RN reported that a Hospice CNA had to clean green slime from the resident's left hand, which had a noticeable odor. The Hospice RN assessed the hand and found no redness or open wounds but placed a washcloth in the hand. The facility staff were informed of this issue during a care conference. Despite these observations and reports, the resident's care plan remained inadequate in addressing the contracture, leading to the deficiency noted by the surveyor.
Failure to Monitor and Document Nutrition and Hydration Intake
Penalty
Summary
The facility failed to consistently monitor and document the nutrition and hydration intake for a resident who required total assistance with eating due to significant medical conditions, including diabetes mellitus, amputation of the right hand, and hemiplegia following a stroke. The resident had orders for one-on-one feeding assistance and documentation of meal and fluid intake at each meal, which were not consistently followed. The resident's care plan was also not updated to include an intervention for staff to offer and provide water every hour, despite a significant weight loss of 14.71% over several months. Observations and interviews revealed that the facility's staff did not consistently document the resident's meal and fluid intake, with numerous missing entries noted in the Treatment Administration Records over three months. The facility's Nursing Home Administrator acknowledged the expectation for CNAs to document fluid intake every shift and confirmed that missing documentation implied the resident did not receive fluids. Additionally, the facility's education efforts to ensure the resident was fed and provided water were limited, with only a few CNAs receiving the training, and agency staff were not informed of the necessary interventions due to the care plan's lack of updates.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as R1, from repeatedly exiting the facility without signing out, which led to a finding of Immediate Jeopardy. R1, who had Huntington's disease, diabetes mellitus, chronic kidney disease, and depression, exhibited moderate cognitive impairment and decreased safety awareness. Despite these conditions, R1 was able to leave the facility multiple times, often found by police walking on highways and country roads, posing significant safety risks. The facility's policy on elopements and wandering residents was not effectively implemented for R1. R1's care plan included interventions such as arranging transportation for appointments and reminding R1 to sign out, but these measures were insufficient. R1's medical record indicated a low risk for elopement, and R1 was not included in the Wander Communication Binder, which was a critical oversight given R1's history of wandering and elopement. Staff interviews revealed a lack of consistent monitoring and intervention strategies for R1. The facility did not have a system to track R1's whereabouts, and staff often relied on police to return R1 to the facility. Despite R1's refusal to wear a Wanderguard, the facility did not explore alternative safety measures or adequately assess R1's risk for elopement, leading to repeated incidents of R1 leaving the facility unsupervised.
Removal Plan
- Educate residents who leave the facility independently to sign out with their location and when they will return.
- Offer R1 transportation to locations not within walking distance.
- Update the Wander Communication Binder.
- Initiate elopement drills.
- Reeducate staff on the elopement/wander policy, including care planning and identification of potential elopement risks.
Failure to Provide Medically-Related Social Services for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to provide appropriate medically-related social services for a resident with a history of suicide attempts and psychiatric needs. The resident, who had Huntington's disease, diabetes mellitus, chronic kidney disease, and depression, was admitted to the facility without a follow-up on psychiatric services after being discharged from the hospital. The resident exhibited unsafe behaviors, such as leaving the facility multiple times and refusing medications, yet the facility did not expedite the guardianship process or ensure the continuation of psychiatric care. The facility's policy on elopements and wandering residents was not adequately followed. Despite the resident's repeated elopements and unsafe behavior, the facility did not reassess the resident's needs or make necessary referrals for psychiatric consultations. The resident's care plan indicated a risk for self-inflicted injury and decreased safety awareness, but the facility's response was insufficient, as evidenced by multiple incidents where the resident left the facility unsupervised and was found in potentially dangerous situations. Interviews with staff and external agencies revealed a lack of timely action and communication regarding the resident's safety and psychiatric needs. The facility did not seek guidance from Adult Protective Services on how to keep the resident safe while awaiting guardianship, nor did they contact the State Ombudsman for advice. The Social Services Designee admitted to not following up on the psychiatric concerns listed in the hospital discharge summary, contributing to the deficiency in care provided to the resident.
Incomplete Background Checks for Staff
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by incomplete background checks for two employees. The Director of Nursing (DON)-B, who was hired in 2020, had a four-year Background Information Disclosure (BID) form completed in 2024, which indicated that the DON had resided outside the state in the past three years. However, the facility did not conduct the required out-of-state background check for DON-B. This oversight was identified during a review of the DON's background check information by a surveyor. Additionally, the facility did not have a fully completed BID form for Laundry Aide (LA)-C, who was hired in 2024. The surveyor found that pages 2 and 3 of LA-C's BID form were missing. The Business Office Manager (BOM)-D, who was new to the Human Resources role, acknowledged the missing documentation and the requirement for a complete BID form. BOM-D also confirmed the necessity of an out-of-state background check for employees who have lived outside the state within the past three years.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The infection surveillance line list for staff was incomplete, lacking critical information such as the well date for HR-G and COVID-19 test results for CNA-F. The Director of Nursing, who also served as the Infection Preventionist, acknowledged these omissions and confirmed that the missing information was an oversight. Inadequate hand hygiene practices were observed during the provision of care for a resident with a urinary catheter. CNA-I failed to perform hand hygiene between glove changes while providing perineal and catheter care, despite the facility's policy requiring such practices. Additionally, CNA-I did not wear the appropriate personal protective equipment (PPE) as indicated by the Enhanced Barrier Precautions (EBP) policy, which was confirmed by both the CNA and the Director of Nursing. The survey also revealed improper storage and use of medical supplies in a resident's room, where used PPE and medical items were found. The resident confirmed that staff used personal supplies for care, contrary to facility policy. Furthermore, LPN-J did not sanitize a blood pressure cuff between uses on two residents, which was not in line with the facility's equipment protocol. The Director of Nursing verified that staff were expected to sanitize equipment between residents unless it was disposable.
Deficiency in Self-Administration of Medication Assessment
Penalty
Summary
The facility failed to ensure a proper self-administration of medication assessment for a resident, identified as R11, who was observed with medication at their bedside. The assessment and physician's order did not accurately reflect the medications R11 was allowed to self-administer. Additionally, R11's care plan did not specify how the medications were to be stored and secured in their room. R11, who had intact cognition and was responsible for their healthcare decisions, was observed to self-administer eye drops, nasal spray, and inhaled medications, but the care plan did not indicate the storage arrangements for these medications. The resident's medical record showed discrepancies between the physician's orders and the medications R11 was self-administering. The Medication Administration Record (MAR) did not include orders for nebulizer treatments, which were mentioned in the physician's order. Furthermore, the Self-Administration of Medication Evaluation indicated that R11 could not correctly administer eye drops or ointments, yet they were self-administering these medications. Interviews with the Director of Nursing confirmed that the care plan should have included storage details and that the physician's order should have been for an albuterol inhaler instead of a nebulizer treatment.
Failure to Complete Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to meet the Pre-Admission Screen and Resident Review (PASRR) requirements for a resident, identified as R7, who was admitted with diagnoses including post-traumatic stress disorder (PTSD), anxiety, and depression. Despite these diagnoses, R7's PASRR Level I Screen inaccurately indicated that the resident was not suspected of having a serious mental illness and did not have a current diagnosis of mental illness. This error led to the omission of a necessary PASRR Level II Screen, which should have been completed to evaluate the need for specialized services and appropriate nursing facility placement. The deficiency was identified during a surveyor's review of R7's medical records and interviews with facility staff. The Minimum Data Set (MDS) assessment for R7 showed moderate cognitive impairment, and previous medical records indicated a history of mental health issues, including suicidal ideation. The facility's MDS coordinator and Director of Nursing acknowledged the oversight, confirming that the PASRR Level I Screen should have reflected R7's mental health diagnoses, necessitating a Level II Screen. This oversight highlights a failure in the facility's adherence to PASRR guidelines, impacting the resident's care assessment process.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to ensure comprehensive resident-centered care plans were implemented for two residents, R7 and R15. For R7, the care plan did not indicate the need for a bed rail, despite the resident expressing a need for bilateral bed rails to assist with positioning and mobility. The facility's policy on bed rails requires a person-centered approach, but R7's care plan lacked a physician's order for bed rail use. Interviews with staff revealed confusion about R7's need for bed rails, with conflicting statements about whether R7 wanted or needed them. The Director of Nursing confirmed that an assessment should have been completed to determine the necessity of bed rails for R7. For R15, the care plan failed to address the resident's request for no caregivers of the opposite gender, despite R15's history of sexual assault. R15 expressed discomfort with a specific CNA, but the care plan did not reflect this preference. The Director of Nursing acknowledged that the individualized intervention should have been included in R15's care plan, especially given the resident's traumatic history. The oversight in both cases highlights a lack of adherence to the facility's policies and procedures for developing and implementing comprehensive care plans.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R21, who required assistance with activities of daily living. R21 had severe cognitive impairment and was dependent on staff for all care. Despite the facility's policy that routine nail care, including trimming and filing, should be provided regularly, R21's toenails were observed to be thick, discolored, overgrown, and curling, with a substance underneath. This condition was noted during observations on two separate occasions, and R21 reported experiencing pain in the big toe. Interviews with facility staff revealed inconsistencies in the provision of nail care. A Certified Nursing Assistant (CNA) stated that nail care was part of daily grooming, while the Assistant Director of Nursing (ADON) indicated that nail care was scheduled weekly on shower days. However, records showed that R21's toenails had not been trimmed since admission. The Director of Nursing (DON) confirmed the need for trimming and acknowledged that nail care should coincide with weekly showers, highlighting a lapse in adherence to the facility's nail care policy.
Deficiencies in Documentation for Assistive Devices
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of two residents, R7 and R10. For R7, the deficiency involved the use of bed rails. R7, who has Parkinson's disease and moderate cognitive impairment, was observed with a bed rail on the left side of the bed, despite the care plan not indicating the need for bed rails. The care plan history showed that bed rails were previously used but discontinued. The Registered Nurse (RN) stated that R7 was not reapproved for bed rail use and admitted that the assessment regarding the need for bed rails was not documented in R7's medical record. The Director of Rehab confirmed that therapy notes did not specifically address bed rail use, and the Director of Nursing acknowledged that an assessment should have been documented. For R10, the deficiency involved the removal of a cane without proper documentation. R10, who has intact cognition and a history of cerebral infarction, reported that a cane belonging to R10's grandfather was taken away by staff. The Director of Nursing stated that the cane was removed because R10 had swung it at staff, and it was kept in the office until deemed safe for R10 to use. However, this discussion and the removal of the cane were not documented in R10's medical record. A progress note indicated that R10 had previously threatened staff with the cane, but there was no documentation of the specific incident leading to the cane's removal. The lack of documentation for both residents highlights a failure in maintaining accurate medical records and ensuring that assessments and decisions regarding assistive devices are properly recorded. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyor, revealing gaps in the facility's compliance with professional standards for medical record-keeping.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident 1, who had cerebral infarction with left-sided paralysis and a below-elbow amputation of the right arm, was observed without a call light within reach. Despite having a soft-touch call light near the left elbow, Resident 1 was unable to use it due to the paralysis and was dependent on staff for all activities of daily living. The care plan did not specify the type or placement of the call light needed to accommodate Resident 1's physical limitations. Similarly, Resident 7, with diagnoses including congestive heart failure and diabetes mellitus, was found unable to reach the call light, which was placed on the bed while the resident was seated in a chair several feet away. Resident 8, who had chronic pain syndrome and anxiety disorder, also could not reach the call light due to its placement on the bed with a bedside table obstructing access. These observations indicate a failure to reasonably accommodate the residents' needs for assistance, as the call lights were not accessible, preventing them from notifying staff when help was needed.
Medication Administration and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the accurate administration of medication for one resident and did not provide safe handling of drugs for another. One resident, who had a history of cerebral infarction, left-sided paralysis, and anxiety disorder, did not receive multiple doses of hydrocortisone as ordered by their physician. Despite a hospital discharge summary indicating the need for hydrocortisone, the facility delayed administering the medication due to an unaddressed allergy concern. The Director of Nursing acknowledged that the endocrinology orders should have been processed earlier and that there was a lack of timely transcription and clarification of physician orders. Another resident, diagnosed with bipolar disorder and an unspecified mental disorder, was observed during medication administration where a registered nurse improperly disposed of a half tablet of buspirone in the garbage. The nurse had to cut a 10 mg tablet in half to achieve the prescribed 15 mg dose, but discarded the unused half inappropriately. The nurse also failed to use a half pill that was taped in a medication card slot because they could not verify its identity. This improper disposal was contrary to the facility's policy, which requires unused medications to be disposed of in a Drugbuster or similar system.
Failure to Document and Investigate Grievances
Penalty
Summary
The facility failed to thoroughly document, investigate, or resolve grievances for two residents. One resident reported that a Certified Nursing Assistant (CNA) did not change their clothing from the previous day, and another resident reported being left wet and ignored by the same CNA. Despite these grievances, the facility did not document or investigate these concerns adequately. The facility's grievance file did not contain records of these grievances, and there was no indication that the issues were resolved. The facility's policy requires prompt efforts to resolve grievances, including documentation and investigation, which were not followed in these cases. The medical records of the two residents involved indicated that one had severely impaired cognition and an activated Power of Attorney, while the other had moderate cognitive impairment and a Guardian for decision-making. Interviews with the residents and staff revealed that the concerns were known but not properly documented or investigated. The Director of Nursing and Nursing Home Administrator acknowledged the lack of documentation and investigation, and it was noted that the CNA involved had received education on proper techniques but was still on their last chance due to ongoing issues.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
