Pine View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Black River Falls, Wisconsin.
- Location
- 400 County Rd R, Black River Falls, Wisconsin 54615
- CMS Provider Number
- 525409
- Inspections on file
- 31
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Pine View Care Center during CMS and state inspections, most recent first.
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 cognitively intact resident with multiple medical conditions, including chronic pain and depression, reported that while receiving a shower from a CNA, another CNA searched through the resident's purse, which had been tucked away in a nightstand, and removed Tylenol and other medications without permission. An RN documented that oxycodone from home was initially found in the purse and later placed in the medication cart, and believed the CNA had removed it from the purse without knowing if permission had been granted. The CNA stated that after a housekeeper found a pill on the floor and gave it to the CNA, a nurse instructed the CNA to search the resident's room, leading to discovery of medications in the purse on the nightstand; the CNA admitted not having permission to go through the resident's belongings. The DON was unaware of the incident but acknowledged that the CNA should not have searched the resident's belongings without consent.
A deficiency occurred when staff did not thoroughly investigate or implement care plan updates and monitoring after a physical altercation between two residents, one cognitively intact and one severely cognitively impaired with multiple comorbidities. During a church service, one resident objected to another playing cards, attempted to remove the cards, and the other resident slapped the resident’s hand away. Although the incident was self-reported and both residents later described it as minor, record review showed no post-incident monitoring, no documentation addressing a resident’s initial fear, and no new interventions or care plan revisions to prevent recurrence, which the DON acknowledged during interview.
A resident admitted after hip replacement surgery, cognitively intact and continent of bladder, had a baseline care plan indicating stand-and-pivot transfers. Shortly after admission, the resident reported that a CNA, unable to locate a bedpan and concerned about pain with transfers, suggested the resident could void in an incontinent brief if unable to wait, which upset the resident. Review of the baseline and comprehensive care plans showed they were not revised to include person-centered, comprehensive interventions following this incident. Staff interviews revealed that CNAs depend on care plans for transfer and toileting instructions, that care plans are expected to be available at admission, and that bedpans are typically stored in a main supply closet, while the DON acknowledged that no immediate care plan interventions were added after the event.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer’s dementia and coronary artery disease, had a care plan requiring Hoyer lift transfers with assistance of two staff. However, staff interviews revealed that CNAs and nursing staff routinely used a sit-to-stand mechanical lift for toileting without a corresponding medical order, while the ADL care plan did not specify equipment for toileting. The RN, DON, and a family member all confirmed that the resident was care planned as a Hoyer lift transfer, and the DON acknowledged there was no current order authorizing the use of the sit-to-stand lift, despite its ongoing use for toileting.
A resident admitted with atrial fibrillation, major depressive disorder, and asthma had multiple missed doses of ordered medications, including ASA, bupropion, famotidine, a fluticasone-salmeterol inhaler, amitriptyline, and duloxetine. Facility policy defined unavailable prescribed drugs as medication errors and required completion of a Medication/Treatment Error Administration Report and timely reporting to the DON or administrator, but no such errors were documented on the incident log. Progress notes contained no evidence that the physician was notified that the medications were unavailable, and the NHA reported being unaware of the missed doses, stating the expectation would have been to contact the physician for further orders.
A resident admitted with atrial fibrillation and other conditions had physician orders for Xarelto and Amiodarone but missed multiple scheduled doses of both drugs because they were unavailable. Nursing documentation noted that one of the medications was held due to unavailability, yet there was no evidence that the provider was notified or that a medication error report was completed, despite facility policy defining unavailable medications as medication errors and requiring timely reporting to the DON or administrator. The NHA later stated they were unaware of the missed doses and that the expectation would have been to contact the physician for further orders.
A resident with dementia and severely impaired cognition, care planned for sit-to-stand lift use for all transfers and dependent for transfers and toileting, was observed being transferred from the bathroom to a wheelchair on a sit-to-stand lift by a single CNA, contrary to facility policy and staff expectations that all mechanical lift transfers require two staff. The CNA acknowledged receiving training, knowing that two staff were required for lift use, and understanding that this resident needed two-person assistance, but proceeded alone because the nurse was busy. Other CNAs, an RN, and facility leadership all confirmed that two-person assistance is required for all lift equipment transfers and that the resident’s care plan called for use of the sit-to-stand lift.
A resident with type 2 DM on a prescribed sliding scale insulin lispro regimen did not receive two ordered insulin doses when blood glucose readings required administration. Facility policy required blood sugar monitoring and sliding scale insulin per MD orders. On two separate occasions, blood glucose values fell within the range requiring 2 units of insulin, but no insulin was given. One missed dose occurred when a nurse became occupied with another resident’s fall and forgot to administer insulin, and the other occurred when a med tech failed to report the blood sugar result to the nurse, resulting in the nurse not giving the ordered dose.
A resident with significant care needs was subjected to verbal abuse and rough handling by a CNA, as witnessed and reported by staff. The resident expressed feeling mistreated and fearful, and the incident was reported to facility leadership. However, the CNA was not removed from resident care during the investigation, which was limited in scope and not reported to the State Agency as required.
The facility did not follow its abuse prevention and reporting policies for two residents. In one case, a CNA was reported for yelling and rough handling, but was not removed from care and the incident was not reported to the State Agency. In another case, staff used a stern tone and inappropriate comments during a transfer, causing anxiety for a resident, but the incident was not fully investigated or reported. Both cases lacked thorough investigation and failed to meet required reporting procedures.
The facility did not report two separate allegations of abuse involving two residents to the State Survey Agency or law enforcement as required. In one case, a staff member reported that a CNA was rough and yelled at a resident, and in another, a family member reported staff using an inappropriate and abrupt approach during a transfer, causing distress to a resident with atrial fibrillation and hypertension. Both incidents were acknowledged by facility leadership as allegations of abuse but were not reported according to policy.
Two residents' allegations of abuse were not thoroughly investigated, with incomplete interviews and no evidence of protective measures or timely reporting to the state. In both cases, staff and family reported rough or inappropriate treatment by CNAs, but the facility failed to follow its abuse policy and regulatory requirements.
A resident with a right below the knee amputation, who required a full body mechanical lift for transfers per their care plan, was transferred using a sit-to-stand mechanical lift by a CNA. This action was not in accordance with the resident's care plan or facility policy, which specifies the use of a full body lift for residents unable to bear weight.
A resident's advance directive was not properly documented or accessible in the facility's records, despite policy requirements to discuss and record CPR/DNR orders upon admission. Staff interviews confirmed the absence of necessary documentation, and hospital transfer documents indicating DNR status were not placed in an accessible location.
A facility failed to maintain a medication error rate of 5% or less, with a surveyor observing 2 errors out of 27 opportunities, resulting in a 7.41% error rate. A resident received insulin injections from pens that were not primed as per manufacturer's instructions, due to the RN's lack of awareness about the priming requirement. The DON was also unsure about the facility's policy on insulin pen use.
The facility failed to maintain food safety standards by serving potentially hazardous foods at improper temperatures and transporting uncovered food trays through hallways. Pureed lasagna was served at 128 degrees Fahrenheit, below the required 135 degrees, affecting two residents on a pureed diet. Additionally, an LPN delivered uncovered food items to residents' rooms, contrary to facility expectations.
A resident dependent on staff for eating was fed in an undignified manner by a CNA who repeatedly wiped food from the resident's face with a spoon and re-fed it to them. The CNA was unaware that this practice was inappropriate, and the DON confirmed it violated dignity and infection control standards.
A resident with severe cognitive impairment and significant health issues did not receive adequate assistance with meals, leading to poor nutrition. Despite care plan instructions and therapy recommendations, staff provided minimal help and did not offer alternative foods or fluids. Observations and staff interviews revealed inconsistent and inadequate meal assistance.
The facility failed to conduct a comprehensive trauma-informed assessment and develop a care plan for a resident with a significant history of trauma and related diagnoses, despite the facility's policy requiring such assessments.
A resident received 10 units of Insulin Aspart (Humalog) 58 minutes before their meal, contrary to guidelines that recommend administering rapid-acting insulin within 0-15 minutes before a meal or immediately after. The RN acknowledged the mistake, and the DON confirmed the correct protocol.
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.
Unauthorized Search of Resident Belongings and Removal of Medications
Penalty
Summary
The deficiency involves a failure to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions when a CNA searched through and removed items from a resident's purse without permission. The resident, who was cognitively intact with a BIMS score of 15/15, had diagnoses including aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder. The resident reported that while receiving a shower from one CNA, another CNA went through the resident's purse, which had been tucked away in the nightstand, and removed Tylenol and other medications without authorization. The resident stated that the CNA had no business being in the purse and did not know if any other items were taken. Subsequent interviews and record review showed that an RN documented that oxycodone was initially found in the resident's purse and that residents could not have narcotics on their person in the building. The RN stated that the oxycodone prescription bottle from home was retrieved from the resident and placed in the medication cart and believed that the CNA had removed it from the resident's purse but did not know if the CNA had permission or where the purse was located. The CNA later stated that a housekeeper had found a pill on the floor and given it to the CNA, who then showed it to a nurse and was told to look through the resident's room to find its source; the CNA reported finding medications in the resident's purse on the nightstand and acknowledged not having permission to go through the resident's belongings. The DON was unaware of the events and acknowledged that the CNA should not have gone through the resident's belongings without permission.
Failure to Investigate and Care Plan After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to an alleged resident-to-resident physical altercation and to implement care plan updates and monitoring for two residents. Facility policy states that all alleged violations will be thoroughly investigated and that, when cause or probable cause is determined, the resident care plan will be revised to ensure a corrective plan is in place to prevent recurrence. An incident occurred in which one resident, who is cognitively intact with a BIMS score of 14/15 and diagnoses including right femur fracture, type 2 diabetes mellitus, muscle weakness, and history of falls, was playing cards during a televised church service. Another resident, who has severe cognitive impairment with a BIMS score of 6/15 and diagnoses including atrial fibrillation, Parkinson’s disease, major depressive disorder, anxiety, chronic kidney disease, and history of falls, believed this was disrespectful, attempted to remove the cards, and the first resident slapped or cuffed the other resident’s hand away. The facility self-reported the incident and documented that the residents agreed to distance themselves and that there was no injury or ill effect, with the cognitively impaired resident later describing the event as a “silly little thing” and a “little slap” that did not leave marks. However, the surveyor’s review of the electronic health record showed no monitoring in place related to the incident or to the cognitively impaired resident’s statement to the Director of Social Services about initially being scared. Care plan reviews for both residents showed no updates or added interventions to prevent recurrence following the altercation. Interviews with both residents confirmed that no one had spoken with the cognitively intact resident about how to prevent a similar incident, and the DON acknowledged that no interventions or care plan updates were implemented after the event.
Failure to Revise Care Plan With Person-Centered Interventions After Toileting Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s comprehensive care plan with person-centered, comprehensive interventions following a reported incident. The resident was admitted after a hip replacement with diagnoses including hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder, and had a BIMS score of 15/15 indicating no cognitive impairment. The baseline care plan dated 04/02/26 indicated the resident was a stand and pivot transfer and was continent of bladder. On 04/03/26, the resident reported that a CNA told the resident to use the incontinent product instead of being assisted to the bathroom because the CNA could not find a bedpan and was concerned about the resident’s pain with transfer. The resident refused to void in the brief and was ultimately assisted to the bathroom but was upset by the situation. Surveyor review of the resident’s baseline and comprehensive care plans showed that no new or revised interventions were added immediately after the reported incident. Staff interviews indicated that care plans and CNA care cards are expected to be created and available at admission, including transfer and bowel/bladder information, and that CNAs rely on these care plans for transfer instructions. One CNA involved in the incident stated there was no care plan ready and no bedpans available, and that the CNA had not received report on how the resident should transfer. Another CNA reported that bedpans are usually kept in the main supply closet and that some staff assume there are none if they are not in the closer, smaller closet. The DON acknowledged that no immediate interventions were placed in the resident’s care plan following the incident.
Improper Use of Sit-to-Stand Lift Contrary to Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and appropriate assistive devices for transfers as outlined in the resident’s care plan. The facility’s policy on the Resident Assessment Instrument and person-centered care planning requires the IDT to develop and modify care plans to provide appropriate care and services. The resident, admitted with diagnoses including Alzheimer’s dementia, coronary artery disease, hypertension, and peripheral vascular disease, had a Minimum Data Set showing a BIMS score of 3/15, indicating severe cognitive impairment. The ADL care plan, dated 11/11/25, specified that the resident was to transfer via Hoyer lift with assistance of two staff, and toileting required assistance of two, though the toileting section did not specify the transfer equipment to be used. Despite the care plan indicating Hoyer lift transfers, staff interviews revealed that CNAs and nursing staff were using a sit-to-stand mechanical lift for toileting. The resident was unable to provide information about transfers due to impaired cognition. A family member reported believing staff used the sit-to-stand lift for toileting and stated that staff should be using what is ordered, but was not aware of improper transfers. An RN confirmed that the resident was supposed to be a Hoyer lift for all transfers but acknowledged that staff used the sit-to-stand lift for toileting and that they were in discussions with Hospice about obtaining an order for this, which had not yet been obtained. A CNA stated it was their understanding that the sit-to-stand use for toileting was ordered by Hospice. The DON confirmed that the care plan listed the resident as a Hoyer lift and acknowledged there was no current order authorizing the use of the sit-to-stand lift for any transfers, even though staff were using it for toileting.
Failure to Ensure Availability and Administration of Ordered Medications and Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate acquiring, receiving, dispensing, and administration of prescribed medications for a resident, and failure to notify the physician when medications were unavailable. The facility’s own Medication/Treatment Administration Error Policy, revised in April 2025, defines a facility medication error as occurring when a prescribed medication is not available to be administered and requires that, upon discovery of a medication error, the nurse complete a Medication/Treatment Error Administration Report and submit it to the DON or administrator within 24 hours. Despite this policy, the facility’s incident logs contained no identified medication errors related to this situation, and there was no documentation that the physician was notified that medications were unavailable. The resident was admitted with diagnoses including atrial fibrillation, major depressive disorder, and asthma, and had physician orders for multiple medications: aspirin 81 mg daily, bupropion HCl ER 300 mg daily, famotidine 40 mg daily, fluticasone-salmeterol inhaler twice daily, amitriptyline 25 mg daily, and duloxetine 60 mg daily. Review of the admission medication record showed the resident missed 3 doses of aspirin, 2 doses of bupropion, 3 doses of famotidine, 11 doses of the fluticasone-salmeterol inhaler, 3 doses of amitriptyline, and 3 doses of duloxetine. Progress notes did not show any physician notification regarding the unavailability of these medications. During interview, the NHA stated they were not aware the resident had not received the ordered medications and indicated the expectation would have been that the physician be contacted for further direction or orders.
Failure to Administer and Report Unavailable Cardiac Medications
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administration of medications for one resident, resulting in multiple missed doses of significant medications without appropriate follow-up. The facility’s own Medication/Treatment Administration Error Policy defines a medication error as occurring when a prescribed medication is not available to be administered and requires completion of a Medication/Treatment Error Administration Report and submission to the DON or administrator within 24 hours of discovery. For this resident, who was admitted with diagnoses including atrial fibrillation, major depressive disorder, and asthma, physician orders included Xarelto 20 mg every evening and Amiodarone 200 mg three times a day. Review of the admission medication record showed the resident did not receive five scheduled doses of Xarelto and eight scheduled doses of Amiodarone. Nursing progress notes documented that Xarelto was held because it was unavailable, but there was no documentation that the physician was notified that Xarelto or Amiodarone were not available for administration. Review of the facility’s incident logs revealed no recorded medication errors related to these missed doses, despite the policy requiring such reporting when medications are unavailable. Further review of the resident’s progress notes did not show any physician notification regarding the unavailability of the medications. During an interview, the NHA stated they were not aware that the resident had not received the medications and indicated that the expectation would have been for the physician to be contacted for further direction or orders.
Failure to Use Required Two-Person Assist for Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible by not following its own policy requiring two staff members for all mechanical lift transfers. The facility’s Body Mechanics - Transfer Training policy, reviewed in 11/2024, specifies that two CNAs, licensed nurses, or therapists are required for mechanical sit-to-stand and full-body lift use. The resident involved, R3, was admitted with dementia and had a BIMS score of 00, indicating cognition not intact. R3’s most recent MDS documented a need for substantial/maximal assistance with bed mobility and dependent assistance with toileting hygiene, sit-to-stand, chair/bed transfers, and toilet transfers. R3’s care plan required use of a sit-to-stand lift for all transfers and documented toileting assistance of one. During observation, the surveyor saw that R3 was transferred from the bathroom to a wheelchair using a sit-to-stand lift by one CNA (CNA D) without a second staff member present. CNA D confirmed she had been trained on safe transfer techniques and knew that two staff were required for lift equipment transfers, and she stated she was aware R3 needed two staff for use of the lift machine but proceeded alone because the nurse was busy and R3 needed to be transferred. Other staff interviewed, including another CNA and an RN, stated that the expectation was that two staff are required for all lift transfers, and review of R3’s care plan by staff confirmed that a sit-to-stand lift was required for transfers, which they understood to mean two staff assistance. Facility leadership also acknowledged that the expectation is for two staff to assist with resident transfers using lift equipment and that this was a concern given repeated staff education on resident safety with lift transfers.
Missed Sliding Scale Insulin Doses for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Facility policy on diabetic blood sugar monitoring, last reviewed in 11/2022, requires that blood sugars be measured and recorded per physician orders and that sliding scale insulin be given as ordered. The resident, admitted with type 2 diabetes mellitus without complications, had a physician order for insulin lispro on a sliding scale four times daily, with specific unit doses tied to blood glucose ranges and an instruction to call the physician for readings over 400. Review of the medication administration record showed that on 02/28/26 the resident’s morning blood sugar was 154, which required administration of 2 units of insulin lispro per the sliding scale order, but no insulin was given. Further review showed that on 03/15/26 the resident’s lunchtime blood sugar was 192, again requiring 2 units of insulin lispro per the physician’s sliding scale order, and no insulin was administered. During an interview on 03/23/26, the Clinical Services Consultant explained that every other weekend a med tech obtains diabetic blood sugars and informs the nurse of the results so the nurse can administer insulin. On 02/28/26, another resident experienced a fall, and the nurse became busy and forgot to administer the ordered insulin dose. On 03/15/26, the med tech did not inform the nurse of the resident’s blood sugar result, and the nurse did not administer the lunchtime insulin dose. The Clinical Services Consultant confirmed that these missed doses constituted medication errors and that insulin should have been administered on both occasions.
Failure to Protect Resident from Verbal Abuse and Rough Handling by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) engaged in verbal abuse and rough handling of a resident who required extensive assistance with activities of daily living due to diagnoses including renal cancer, urine retention, and hydronephrosis. The resident reported feeling like an animal during care and expressed fear of staff, stating that staff were rough and used inappropriate language. The resident also indicated that they had reported these concerns to facility leadership. Multiple staff interviews confirmed that the CNA was observed swearing at the resident and handling them roughly during care. A housekeeper witnessed the CNA cursing at the resident and placing their legs harshly on wheelchair pedals, and reported hearing the CNA yelling from down the hall. The housekeeper reported the incident to a Registered Nurse (RN), who in turn reported it to the Nursing Home Administrator (NHA). However, neither the housekeeper nor the RN intervened to remove the resident from the situation or to have the CNA leave the room at the time of the incident. Despite the allegations and reports, the CNA was not removed from resident care during the investigation. The facility's investigation was limited, consisting of only three handwritten staff interviews without times or signatures, and did not include interviews with other staff or residents. The incident was not reported to the State Agency as required, and the NHA acknowledged that the event constituted an allegation of abuse but did not take further investigative or protective actions.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures prohibiting abuse, neglect, and mistreatment for two residents. In the first instance, a housekeeper reported to a registered nurse that a certified nursing assistant (CNA) was yelling, swearing, and handling a resident roughly during care. The registered nurse reported the incident to the nursing home administrator, but the CNA was not removed from resident care during the investigation. The facility's investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, and no additional interviews with other staff or residents were conducted. The incident was not reported to the State Agency as required by facility policy. In the second case, a family member raised concerns about staff approach and communication during a transfer of another resident who had recently transitioned to using an EZ stand. The family member reported that staff were abrupt, used a stern voice, and made inappropriate comments, causing the resident to become anxious and confused. The staff told the resident she could remain in the chair and go to the bathroom there, then left the room without assisting further. The family member reported the incident to the social worker, who documented it as a grievance. The social worker and administrator both acknowledged the incident could be considered abuse, but the incident was not reported to the State Agency, and a full investigation was not completed. Both incidents demonstrate that the facility did not follow its own abuse policy, which requires immediate safeguarding of residents, thorough investigation of all allegations, and timely reporting to the State Agency. In both cases, the facility failed to remove the alleged perpetrator from resident care during the investigation, did not conduct comprehensive interviews, and did not report the allegations as required by policy and regulation.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the facility administrator and to the State Survey Agency, as well as to law enforcement, as required by both facility policy and state law. In two separate cases, allegations of abuse were not reported to the appropriate authorities. In the first case, a staff member reported that a CNA was yelling at and being rough with a resident. The Nursing Home Administrator (NHA) acknowledged receiving the report and initiating an investigation but did not report the incident to the State Agency or law enforcement. Documentation of the investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, with no additional interviews from other staff or residents. In the second case, a family member raised concerns about the manner in which staff transferred a resident using an EZ stand, describing the staff's approach as abrupt and inappropriate. The family member reported that staff made negative comments about the resident, such as calling her non-compliant and unmotivated, and told her she could remain in her chair or fall on the floor. The resident became emotional, tearful, and confused as a result. The incident was reported to the facility's social worker and documented as a grievance. Both the social worker and the NHA acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours, but no such report was made to the State Agency or law enforcement. The residents involved included one with diagnoses of atrial fibrillation and hypertension, who was newly admitted and unfamiliar with the EZ stand transfer device. The failure to report these allegations of abuse as required by policy and regulation represents a deficiency in the facility's abuse reporting procedures. The events were substantiated through interviews with staff, the NHA, the social worker, and the family member, as well as review of grievance documentation.
Failure to Thoroughly Investigate and Protect Residents Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse involving two residents were thoroughly investigated, as required by its own policies and federal regulations. In the first instance, a staff member reported that a certified nursing assistant (CNA) was rough and yelled at a resident during a transfer, with the resident's pant leg becoming stuck in the wheelchair. The facility's investigation consisted only of three handwritten interviews lacking interview times and signatures, and did not include interviews with other staff or residents. The nursing home administrator confirmed that no additional interviews were conducted and that the CNA was not suspended or removed from patient care during the investigation. There was also no evidence that protective measures were put in place to prevent further potential abuse during the investigation process. In the second instance, a family member reported concerns about the approach staff used while transferring another resident with an EZ stand, describing the staff as abrupt and communicating inappropriately. The family member stated that staff made negative comments about the resident's motivation and compliance, and told the resident she could remain in the chair. The facility provided interviews with the resident, the family member, and two CNAs (only one of whom was present during the incident). Although the facility provided documentation of staff education on resident approach and abuse policy, the nursing home administrator acknowledged that a full investigation was not completed and that the incident was not reported to the state as required. Both cases demonstrate that the facility did not follow its own abuse policy, which mandates immediate safeguarding of residents, thorough investigation of all alleged violations, and reporting to the state agency within specified timeframes. The lack of comprehensive investigations and failure to implement protective measures for the residents involved resulted in noncompliance with regulatory requirements for responding to allegations of abuse.
Improper Transfer Method Used for Resident with Amputation
Penalty
Summary
A deficiency occurred when a resident with a right below the knee amputation, who was care planned for transfer with a full body mechanical lift and assistance of two staff, was instead transferred using a sit-to-stand mechanical lift. The facility's policy specifies that residents who cannot sit, stand, or bear weight should not be lifted manually and require a mechanical assist. Despite this, a Certified Nursing Assistant (CNA) used a sit-to-stand lift for the transfer, contrary to the resident's care plan and facility policy. This action was confirmed through interviews with the CNA and the Nursing Home Administrator, as well as review of the resident's care plan and facility policy.
Failure to Maintain Advance Directive for Resident
Penalty
Summary
The facility failed to formulate and maintain an advance directive for Resident 185, which is a requirement to honor the resident's right to request, refuse, and/or discontinue treatment. Upon admission, the facility's policy mandates that a licensed nurse or social worker discuss options such as Cardiopulmonary Resuscitation (CPR) or Do-Not-Resuscitate (DNR) orders with the resident or their legal representative and obtain the corresponding physician orders. However, during the survey, it was found that Resident 185 did not have any orders for CPR or DNR on file, nor was there a Provider Orders for Scope of Treatment (POST) form available in the resident's hard charts or electronic records. Interviews with facility staff, including a Registered Nurse and a Quality Consultant, revealed that the usual process for determining a resident's CPR or DNR status involved checking the most recent signed orders in the hard charts. Despite this, no such orders were found for Resident 185, and the staff acknowledged that the necessary documentation was not accessible. Although there were hospital transfer documents indicating the resident's DNR status, these were not placed in a location where staff would typically look during an emergency. The Quality Consultant confirmed that the DNR orders were not in the expected location and took steps to contact the hospital for the necessary documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as observed during a medication administration task. The surveyor noted 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This deficiency affected one resident, who received two insulin injections using injectable pens that were not properly primed according to the manufacturer's instructions. The insulin pens used were Basaglar Kwikpen (insulin glargine) and Insulin Aspart, both requiring priming to ensure accurate dosing. During the observation, a registered nurse (RN) did not prime the insulin pens before administering the doses to the resident. The RN was unaware of the need to prime the pens, indicating a lack of training or knowledge regarding the proper procedure. The Director of Nursing (DON) was also uncertain about the facility's policy on insulin pen use and whether priming was necessary, although they later acknowledged the manufacturer's instructions were not followed. This oversight in medication administration procedures led to the identified deficiency.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage, preparation, distribution, and serving of food. Surveyors observed that potentially hazardous foods were not served at appropriate temperatures, which could increase the risk of illness for residents. During the survey, it was noted that food items such as pureed lasagna were served at temperatures below the required 135 degrees Fahrenheit. The Dietary Aide recorded a temperature of 128 degrees Fahrenheit for the pureed lasagna, which was not reheated before being served to residents on a pureed diet. This oversight affected two residents who were served the pureed meal without the necessary temperature adjustments. Additionally, the facility did not cover food items while transporting room trays through hallways and past resident rooms. Observations included uncovered bowls of cereal, juice, and coffee being delivered to residents' rooms by an LPN, who walked significant distances with the exposed food. This practice was contrary to the facility's expectations, as stated by the Dietary Manager, who acknowledged that food should be covered when transported outside of the holding cart. These deficiencies in food handling and transportation practices were identified during the survey, highlighting lapses in maintaining food safety standards.
Resident Fed in Undignified Manner
Penalty
Summary
The facility did not assist one resident with eating in a dignified manner. The resident, who is dependent on staff for eating, was observed being fed by a Certified Nursing Assistant (CNA) who repeatedly wiped food from the resident's lower lip and chin with a spoon and then fed the food back to the resident. This practice was observed during both lunch and breakfast on separate days. The CNA indicated that she was not aware that using a spoon to wipe food from a resident's face and refeeding it to them was undignified and had not been instructed otherwise. The Director of Nursing (DON) confirmed that it is inappropriate for staff to wipe residents' chins or lips with a spoon and re-feed them due to dignity and infection control reasons. The facility's policy on Meal Service Standards, which emphasizes serving residents in a dignified and courteous manner, was not followed in this instance. The DON indicated that staff reeducation would be initiated to address this issue.
Failure to Provide Adequate Assistance with Meals for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment received the necessary assistance with meals to maintain good nutrition. The resident, who has Alzheimer's disease and other significant health issues, was observed struggling to eat independently during multiple meal times. Despite the resident's care plan and speech therapy recommendations indicating the need for verbal cues and physical assistance during meals, staff provided minimal assistance and did not offer alternative foods or fluids when the resident did not consume the provided meal. During lunch, the resident was observed eating only a small portion of the meal and engaging in inappropriate eating behaviors, such as pouring juice over the meal and attempting to drink milk with a spoon. Staff made only one attempt to assist the resident and did not offer any alternative foods or fluids. Similarly, during breakfast, the resident was left unattended for extended periods, and staff did not provide timely assistance or offer alternative foods. The resident consumed very little of the meal and was not given additional fluids or finger foods despite the care plan's instructions. Interviews with staff revealed a lack of consistent and adequate assistance for the resident during meals. The Certified Dietary Manager was unaware of the specific issues observed and stated that finger foods and double breakfasts were provided, but these were not observed during the survey. The Registered Dietitian and Speech Therapist confirmed the resident's need for assistance and direction during meals. The Director of Nursing and a Registered Nurse acknowledged the deficiency and indicated plans to educate staff and address the issue immediately.
Failure to Conduct Trauma-Informed Assessment and Care Planning
Penalty
Summary
The facility failed to comprehensively assess a resident (R31) for trauma-informed care and develop care plan approaches to mitigate any triggers to prevent re-traumatization. The facility's policy on providing culturally competent and trauma-informed care requires a multi-faceted approach to identifying resident history of trauma and cultural preferences, including the use of various assessment tools. However, the surveyor found that no trauma-informed assessment was conducted for R31, who is a military veteran with diagnoses including PTSD, alcohol dependence in remission, bipolar disorder, and other mood disorders. R31 reported no recollection of any facility staff discussing his history or potential stress triggers with him. The Assistant Nursing Home Administrator (ANHA) confirmed that a comprehensive trauma-informed assessment was not completed for R31, and thus no care plan was developed to address potential triggers. Although the ANHA mentioned having a conversation with R31 about his diagnosis and potential triggers, there was no documentation of this discussion in R31's record. The lack of a comprehensive assessment and care plan for R31, despite his significant history of trauma and related diagnoses, constitutes a deficiency in providing trauma-informed care as per the facility's policy.
Improper Timing of Insulin Administration
Penalty
Summary
The facility did not provide pharmaceutical services to meet the needs of a resident reviewed for insulin administration. Specifically, a registered nurse (RN) administered 10 units of Insulin Aspart (Humalog) to the resident's right arm at 6:59 AM, but the resident did not begin eating their meal until 7:57 AM, which was 58 minutes after the insulin was given. This timing is inconsistent with guidelines that rapid-acting insulins should be administered within 0-15 minutes before a meal or immediately following a meal to optimize blood sugar control. During an interview, the RN acknowledged that she thought the meal would be served around 7:30 AM and admitted that she should have ensured the insulin was administered closer to the meal time. The Director of Nursing (DON) confirmed that the expectation is for rapid-acting insulin to be administered within 5-10 minutes of a meal or right after. The surveyor explained the observation to the DON, who stated that she would address the issue with education.
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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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