Resolve At West Allis Respiratory And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in West Allis, Wisconsin.
- Location
- 9047 W Greenfield Ave, West Allis, Wisconsin 53214
- CMS Provider Number
- 525108
- Inspections on file
- 45
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Resolve At West Allis Respiratory And Rehab during CMS and state inspections, most recent first.
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.
A resident, who typically submits grievances via email due to physical limitations, sent an email grievance to the NHA alleging neglect by a staff member. The NHA, who was out of town and not monitoring email, did not review the message until several days later and only then recognized it as an allegation of neglect and reported it to the State Agency. Review of the facility reported incident showed that the allegation was not reported within the required 24-hour timeframe, in violation of the facility’s abuse/neglect reporting policy.
A dependent diabetic resident with moderate cognitive impairment, total assistance needs for personal hygiene and bathing, and weekly ordered showers was repeatedly observed with long, dirty fingernails despite a facility policy requiring routine nail cleaning, inspection, trimming, and filing during ADL care. Over a six‑month review of CNA shower sheets, nail care was never documented as completed, and an LPN acknowledged that fingernail trimming for diabetic residents is not documented and had not noticed this resident’s nail condition until it was pointed out, indicating that necessary nail care services were not provided as required.
Surveyors found that the facility failed to provide required written transfer/discharge notices and complete bed-hold documentation for three hospitalized residents. For a cognitively intact resident with quadriplegia and other conditions, transfer notices were signed only by staff, not acknowledged by the resident or representative, and there was no evidence they were provided in writing in a language understood; associated bed-hold forms lacked a checked reason for the hold and omitted the per diem rate. For another resident with acute respiratory failure, tracheostomy, and cognitive deficits who had a guardian, multiple hospitalizations showed transfer notices without the guardian’s written acknowledgment, bed-hold forms where LPNs—not the guardian—consented to hold the bed, and no documented daily rate. A third ventilator-dependent resident with a legal guardian had bed-hold forms signed by an LPN on the representative line, no guardian signatures on transfer notices, and no per diem rate recorded. The NHA confirmed that only verbal consent is obtained, no written copies are sent to representatives, and that daily bed-hold rates are not documented on the bed-hold notices.
Surveyors identified that the facility’s medication error rate exceeded 5% due to two eye drop administration errors among 31 opportunities. In one case, an LPN administered Prednisolone Acetate 1% eye drops to a resident without properly shaking the bottle, despite a “shake well” label. In another case, a CMA administered Cromolyn Sodium 4% eye drops to a resident by instilling two drops into each eye consecutively without waiting the required interval between drops, contrary to the DON’s stated standard of one minute between drops of the same ophthalmic medication.
A resident admitted with a surgically treated femur fracture had an order for acetaminophen 1000 mg PO q6h for pain that was entered incorrectly in the electronic system as a pharmacy-type order instead of a standard medication MAR order, so it never appeared on the MAR. Over several months, staff reviewed and used the MAR for medication administration, and an LPN confirmed only eye drops and insulin were being given, resulting in 589 missed doses of acetaminophen despite ongoing documentation from an APNP and an orthopedic clinic that the resident should continue this regimen. The nurse manager later identified the incorrect order type as the reason nurses could not see the medication, and the DON reported that no pharmacy recommendation had been received to correct the issue.
A resident with a tracheostomy, gastrostomy tube, and indwelling catheter, on EBP and NPO with continuous tube feeding, received ET medications from an LPN who did not follow infection control policies. The LPN removed the resident’s graduated cylinder and syringe from the room, placed the cylinder on the medication cart leaving fluid on the cart, and did not sanitize the cart before preparing medications for other residents. While wearing contaminated PPE, the LPN exited the EBP room, accessed a shared spoon container on the medication cart, and returned to care for the resident without removing PPE or performing hand hygiene. The LPN repeatedly wiped the syringe, including the tip that connects to the ET, with contaminated gloves after fluid overflow. The ADON and DON confirmed these actions were inconsistent with facility policies requiring resident-specific items to remain in the room, PPE removal and hand hygiene before accessing the cart, and protection of the syringe tip from contamination, resulting in a cited infection control deficiency.
A resident with multiple medical conditions was left alone with physician-ordered medications by an LPN who was unaware of the resident's approval status for self-administration. The DON confirmed that the resident had not been approved for self-administration, and facility policy requires staff to observe medication consumption and ensure only approved residents self-administer medications. This resulted in a failure to follow required procedures for medication administration.
Two residents did not receive their scheduled medications within the required time frames, with multiple instances of late administration documented for pain and muscle spasm medications. Despite facility policy requiring medications to be given within one hour of scheduled times, audit reports showed delays ranging from 42 minutes to over three hours, impacting the effectiveness of prescribed pharmaceutical services.
A nurse failed to prime a new insulin pen before administering insulin to a resident with diabetes, contrary to facility policy and standard practice. Additionally, insulin doses for the same resident were repeatedly administered several hours late on multiple occasions, despite staff being educated on proper medication timing.
Two residents with stage three pressure ulcers were observed receiving wound care in which the Wound Care Nurse did not consistently remove dirty gloves, sanitize hands, or use clean gloves at appropriate times. The nurse also failed to sanitize the overbed table and scissors before use, and did not open dressing supplies prior to care, resulting in lapses in infection control practices.
A resident with a history of pressure injuries and total care needs developed a pressure ulcer on the left ear that was not comprehensively assessed or promptly reported to a provider. Staff did not consistently follow wound care recommendations for daily treatment, instead providing care only three times a week, even as the wound worsened. The care plan intervention to use a neck pillow for offloading was not implemented, as the resident was repeatedly observed without it and staff were unaware of the intervention. These failures resulted in delayed and inadequate pressure ulcer care.
A resident with a facility-acquired sacral pressure injury was observed receiving wound care by an LPN who wore gloves but failed to don a disposable gown, despite CDC signage requiring both gloves and gowns for high-contact care activities under Enhanced Barrier Precautions. The LPN performed proper hand hygiene, but the omission of the gown was acknowledged by both the NHA and DON as not meeting infection control requirements.
A resident's family member was not provided a timely refund after making private payments while a Medicaid application was pending, despite facility policy requiring refunds for retroactive Medicaid coverage. Staff interviews revealed confusion and lack of awareness regarding the refund process and status.
A resident's care plan did not accurately reflect their current DNR code status, despite updated physician orders and documentation in the EMR. The resident was moderately cognitively impaired and unable to make decisions, with a family member as the activated decision maker. Staff interviews confirmed the care plan was not updated to match the resident's actual code status.
Staff failed to follow infection control protocols during wound care and respiratory treatment for two residents under Enhanced Barrier Precautions. An ADON did not perform hand hygiene between glove changes while providing wound care to a resident with a stage 3 pressure ulcer, and a respiratory therapist did not wear a gown while administering a nebulizer treatment to a resident with a tracheostomy. Both actions were inconsistent with facility policy and CDC guidance.
A resident with multiple complex medical conditions was transferred to the hospital without notification to their family representative and activated POA, as required by facility policy. Review of records and staff interview confirmed the lack of notification following the transfer.
Two residents experienced staff-to-resident abuse, including verbal/emotional abuse by an RN and physical abuse by a CNA. In one case, a cognitively intact resident with quadriplegia reported emotional distress after overhearing an RN refuse to care for him. In another, a resident with diabetes and COPD was physically struck by a CNA during care, as witnessed by another staff member. Both abuse allegations were substantiated by facility investigations.
A resident with diabetes and COPD, who was cognitively intact, was involved in an incident where a CNA allegedly used physical force and vulgar language. The event was not reported to administration until 14 hours after it occurred, due to staff assuming another manager had already reported it. This delay was contrary to facility policy requiring immediate reporting of suspected abuse.
A resident with quadriplegia and orthostatic hypotension received Midodrine despite physician orders to hold the medication if systolic blood pressure was above 110. Documentation showed the medication was administered multiple times outside the ordered parameters, and both the resident and DON confirmed these errors occurred.
A resident with End Stage Renal Disease did not have their AV fistula monitored for bruit and thrill as required. The facility's policy and professional guidelines were not followed, and there was no active order for monitoring from the end of the last survey until the current survey began. Staff interviews revealed inconsistencies in understanding the monitoring requirements. The issue was identified during an audit, but corrective actions were not implemented until after the survey started.
A resident with a Stage 4 pressure injury did not receive incontinence care before a dressing change, potentially contaminating the wound with fecal matter. The LPN and ADON failed to clean the resident's skin, leaving the resident on a soiled pad. Despite the LPN's claim of no visible feces on the dressing, the surveyor noted the risk of contamination due to the proximity of stool to the wound.
A resident with multiple health issues, including muscle weakness and chronic kidney disease, expressed a desire to return home but lacked an effective discharge plan. The facility failed to identify specific barriers, education needs, and necessary equipment or home services for a successful discharge. Staff communication and documentation were inadequate, leading to an ineffective discharge planning process that did not focus on the resident's goals and safety.
A resident with hemiplegia and cognitive deficits did not receive requested grooming services, such as nail trimming and face shaving, due to the facility's reliance on the resident's refusal of showers as a reason. Despite the resident's care plan indicating the need for assistance with ADLs, the facility did not provide these services, leading to a deficiency noted by surveyors.
A resident with quadriplegia and anxiety was unable to email grievances due to a facility policy change, which was not effectively communicated. The facility's grievance process lacked clarity and did not provide written decisions as required. Staff inconsistencies and failure to accommodate the resident's physical limitations led to a deficiency in honoring the resident's rights.
A facility failed to report an incident of alleged verbal abuse and possible neglect involving a resident to the Nursing Home Administrator and State agency within the required timeframe. The incident, witnessed by a Med Tech, involved a staff member yelling at a resident and refusing to change him while he was soiled. The delay in reporting this incident constitutes a deficiency in the facility's adherence to its policy on reporting abuse and neglect.
A resident with severe cognitive impairment did not receive prescribed doses of Tramadol and Lorazepam due to a medication administration failure. The RN Supervisor removed medication cards from an unlocked cart, resulting in missed doses. The Med Tech documented the medications as unavailable and reported the issue, which was later resolved by the RN Supervisor returning the medications.
The facility's Water Management Plan was outdated and failed to identify and control Legionella risks, with inadequate monitoring and inconsistent documentation. The plan did not reflect current standards or team members, and the Director of Maintenance was unaware of the plan, indicating a lack of training and implementation. These deficiencies posed a risk of Legionella growth and spread within the facility.
A resident with limited range of motion was observed multiple times without the prescribed palm protectors, despite the care plan indicating they should be applied daily. The resident, with a history of several medical conditions, reported not knowing where the splints were. Facility documentation indicated the protectors were applied, but there was no documentation of refusal, highlighting a deficiency in adherence to the care plan and documentation practices.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45% during a medication pass. An LPN crushed medications for a resident, including Cinacalcet and Pantoprazole, which were contraindicated for crushing. Despite a physician's order allowing for medications to be crushed unless contraindicated, the LPN proceeded with the error. The issue was acknowledged by the LPN and reported to the ADON, but no further information was provided.
The facility did not ensure insulin vials for two residents were labeled with expiration dates as per professional standards. Insulin for two residents was opened and used without being dated, contrary to facility policy and guidelines. Staff were unable to provide additional information or ensure compliance during the survey.
The facility failed to report an allegation of exploitation involving a resident and an LPN to the State Survey Agency. The resident reported buying gifts for the LPN, but the DON did not believe the allegation was valid due to the resident's mental state and did not report it. The facility's grievance log did not show any grievance filed by the resident regarding this issue.
The facility failed to investigate allegations of a resident buying gifts for an LPN, despite the resident reporting the issue and calling the police. The DON and NHA were aware of the situation but did not conduct a thorough investigation as required by the facility's policy.
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.
Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
The facility failed to ensure that an alleged violation of neglect was reported to the State Agency immediately, and no later than 24 hours after the allegation was made, as required by facility policy and regulation. The facility’s Abuse, Neglect and Exploitation policy states that all alleged violations must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. One facility reported incident (FRI) showed that the facility received an email grievance from a resident alleging neglect by a staff member, but the allegation was not reported to the State Agency within the required timeframe. The Nursing Home Administrator (NHA), who serves as the facility’s grievance officer, stated that the resident routinely submits grievances via email due to physical limitations that make writing difficult. The NHA reported that the email containing the neglect allegation was sent by the resident on a weekend evening while the NHA was out of town and not checking email. The NHA acknowledged receiving the email on the evening it was sent but did not open or review it until returning to work several days later, at which point the NHA recognized it as an allegation of neglect and reported it to the State Agency. Surveyor review confirmed that the FRI was not submitted to the State Agency until several days after the resident’s initial email notification, exceeding the 24-hour reporting requirement, and no additional explanation was provided for the delay beyond the NHA not monitoring email continuously.
Failure to Provide Routine Nail Care for a Dependent Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary nail care services to a dependent resident in accordance with its nail care policy and the resident’s ADL needs. The facility’s undated Nail Care policy requires routine cleaning, inspection, trimming, and filing of nails on an ongoing basis during ADL care and on a regular schedule, with additional care as needed. The resident, who had diagnoses including diabetes, atrial fibrillation, COPD, and depressive and anxiety disorders, had an MDS assessment showing moderate cognitive impairment (BIMS score of 9) and total dependence on staff for personal hygiene, showering/bathing, dressing, toileting, and oral hygiene. Despite this, the resident was repeatedly observed over several days with long fingernails approximately 1/2 inch in length and visibly dirty underneath. Review of the resident’s care plan documented total dependence for ADLs related to weakness, decreased mobility, and pain, and physician orders specified weekly showers with nursing skin observation. CNA shower review sheets over a six‑month period showed no documentation that nail care was ever completed, and there was no nursing documentation of nail care in the comment sections. An LPN stated that nurses are responsible for trimming fingernails of diabetic residents, typically in connection with showers when CNAs identify the need, and also acknowledged that fingernail trimming is not documented. The LPN reported not having noticed the resident’s long and dirty fingernails until they were pointed out by the surveyor, at which time the condition of the nails was confirmed. These observations and records demonstrate that the resident, who was dependent for ADLs and at risk due to diabetes, did not receive routine nail cleaning and trimming as required by facility policy.
Failure to Provide Written Transfer Notices and Complete Bed-Hold Documentation for Hospitalized Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notices and complete bed-hold documentation, including the per diem rate, for three residents during hospitalizations. Facility policy titled “Bed Hold Notice” (revised 8/2025) requires that residents and/or their representatives receive written information about bed-hold practices both at admission and at the time of transfer for hospitalization or therapeutic leave, including the duration of any state bed-hold policy, reserve bed payment policy, facility bed-hold policies, and conditions for return. The policy also requires written notice of bed-hold policies within 24 hours of an emergency transfer, documentation of attempts to reach representatives, and retention of a signed and dated copy of the bed-hold notice in the resident’s record. Interviews with the Nursing Home Administrator (NHA) confirmed that the facility only obtains verbal acknowledgement for transfer/discharge and bed-hold notices and does not provide written copies to representatives, and that the per diem rate varies by level of care. For one resident with quadriplegia, epilepsy, dysphagia, insomnia, anxiety disorder, and major depressive disorder, who was cognitively intact per a BIMS score of 15, the facility completed transfer notices for two hospitalizations. The first transfer notice documented the transfer date, a general reason that the transfer was necessary for the resident’s welfare, and specified “Sent out for NP (nasal prongs)” as the reason, and included required agency contact information for appeals. However, the notice was signed only by a facility employee and not acknowledged by the resident or representative, and there was no documentation that the notice was provided in writing in a language understood by the resident or representative. The associated bed-hold notice did not have the reason for the bed hold (hospital admission vs. therapeutic leave) checked and did not include the facility’s basic per diem rate, although it documented that the POA agreed to the bed hold. For the second hospitalization, the transfer notice again was signed only by a facility employee, did not specify the reason for transfer in the “Specify” field, and there was no evidence that the resident or representative received the notice in writing in a language they understood. The corresponding bed-hold notice indicated admission to the hospital and that the representative requested a bed hold and received verbal notice, but again omitted the basic per diem rate. For a second resident with acute respiratory failure with hypoxia, tracheostomy status, and cognitive communication deficit, whose MDS documented short- and long-term memory problems and that the resident was rarely understood and rarely understood others, and who had a guardian, multiple hospitalizations occurred. For each hospitalization, the facility generated a notice of transfer and a bed-hold notice. On one hospitalization, the transfer notice contained a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice showed an LPN consenting to hold the bed without evidence of guardian consent and without a documented daily rate. On a subsequent hospitalization, the same pattern occurred: no guardian signature on the transfer notice, an LPN consenting to the bed hold, and no daily rate on the bed-hold form. For two later hospitalizations, the transfer notices documented that verbal consent was obtained from the guardian, but there was no evidence that written notices were provided to the guardian, and the bed-hold forms again lacked the daily rate. The NHA confirmed that nurses complete these forms, that only verbal consent is obtained, that no written copies are sent to representatives, and that consent to hold a bed should come from the resident or representative, not from facility staff. For a third resident with chronic respiratory failure, ventilator dependence, encephalopathy, dysphagia, tracheostomy status, and traumatic subdural hemorrhage, who had a legal guardian, similar issues were identified. During one hospitalization, the bed-hold notice showed an LPN signing on the resident representative’s signature line to consent to holding the bed, with no evidence of the guardian’s consent and no daily rate documented. During a later hospitalization, the notice of transfer included a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice again lacked evidence of guardian consent and did not include the daily rate. In interviews, the NHA reiterated that only verbal consent is obtained for transfer and bed-hold notices, that no written copies are sent to representatives, and that the daily bed-hold rate is only listed in admission paperwork, not on the bed-hold notices themselves. Surveyors noted the absence of written notices to representatives, the lack of resident/representative signatures acknowledging receipt, the improper substitution of staff signatures for representative consent on bed holds, and the omission of the per diem rate on all reviewed bed-hold forms for these residents.
Medication Error Rate Above 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 medication errors in 31 opportunities, resulting in a 6.45% error rate. For one resident (R7), a surveyor observed an LPN retrieve Prednisolone Acetate Ophthalmic Solution 1% from a medication cart; the eye drop bag had a blue sticker instructing to “shake well.” The LPN entered the resident’s room, checked the resident’s blood sugar, performed hand hygiene, donned gloves, and then administered one drop of Prednisolone Acetate 1% into the resident’s left eye without shaking the bottle. The surveyor did not observe any shaking of the eye drop bottle prior to administration. When questioned later, the LPN stated she had shaken the drops by tipping the bottle down and back up, and the nurse manager demonstrated that “shake well” should involve moving the hand back and forth quickly multiple times, confirming that the observed technique did not meet the expected standard. In a separate incident involving another resident (R9), a surveyor observed a CMA prepare multiple medications, including Cromolyn Sodium Ophthalmic Solution 4%. After verifying the oral medications, the CMA donned gloves and a gown, entered the resident’s room, and administered the oral medications with water. The CMA then informed the resident about the eye drops, handed the resident a tissue, and instilled two drops of Cromolyn Sodium 4% into the left eye while counting “one, two,” followed immediately by two drops into the right eye in the same manner, without waiting any time between drops in either eye. Later, when the DON was asked about proper eye drop administration, the DON stated that staff should wait one minute between drops of the same eye medication and three to five minutes between different eye medications. The surveyor’s observation that no waiting period occurred between drops for this resident constituted a second medication error.
Failure to Transcribe Acetaminophen Order to MAR Resulting in Multiple Missed Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a standing order for acetaminophen 1000 mg by mouth every six hours for pain/discomfort, with a start date of 8/21/25, was not correctly entered into the electronic system and therefore did not appear on the resident’s MARs. The facility’s medication orders policy requires that each medication order be documented on the physician order sheet and the MAR, and that newly prescribed medications be transcribed or ensured to appear in the electronic MAR. Despite this, the acetaminophen order, which was present under the physician orders tab, was not listed on the resident’s MARs for multiple consecutive months, resulting in the resident missing 48 doses in August, 120 in September, 124 in October, 120 in November, 124 in December, and 53 in January, for a total of 589 missed doses. The resident had been admitted with a left periprosthetic distal femur fracture treated surgically and had ongoing pain management needs, with documentation from an APNP and an orthopedic clinic after-visit summary confirming continued orders for acetaminophen 1000 mg every six hours. Surveyor review of the MARs for August through January confirmed the absence of the acetaminophen order despite its presence in the physician orders. During medication pass observation, the LPN administered only eye drops and insulin to the resident and confirmed there were no other medications to be given at that time. When questioned, the nurse manager/LPN explained the facility’s process for entering new admission medications, including using the hospital after-visit summary and a three-check review system, and confirmed that the physician orders tab reflected current orders. Upon reviewing the resident’s electronic orders, the nurse manager identified that the acetaminophen order type had been incorrectly entered as “pharmacy” instead of “standard medication MAR,” which prevented it from appearing on the MAR and from being visible to nurses during medication administration. The DON reported that the facility also relies on remote pharmacy checks and recommendations but stated that no pharmacy recommendation had been received regarding this resident’s acetaminophen order.
Failure to Follow Infection Control Practices During Enteral Tube Medication Administration Under EBP
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during enteral tube (ET) medication administration for one resident on Enhanced Barrier Precautions (EBP). The resident had acute respiratory failure with hypoxia, a tracheostomy, a gastrostomy tube, an indwelling urinary catheter, was NPO with continuous tube feeding, and was dependent on staff for all ADLs. Facility policies required keeping the medication cart clean and using EBP, including gown and gloves for high-contact care involving devices such as feeding tubes, tracheostomies, and catheters, and disposing of PPE before exiting the room or before providing care to another resident. During a medication pass, an LPN prepared and administered ET medications for this resident and did not consistently follow infection control practices. After initially performing hand hygiene and donning PPE, the LPN brought the resident’s graduated cylinder and syringe, prefilled with water and used for ET care, out of the resident’s room and placed the cylinder on the medication cart, leaving a puddle of fluid of unknown contamination on the cart. The LPN did not sanitize the cart and later placed medication cups and a stethoscope on the same contaminated surface. The LPN also repeatedly wiped the syringe, including the tip that connects directly to the resident’s ET, with a contaminated gloved hand after water or medication mixture dripped down the syringe during flushing and medication administration attempts. While wearing PPE in the EBP room, the LPN exited the room without removing gown and gloves or performing hand hygiene and accessed a shared spoon container on the medication cart used for all residents, then returned to the room and continued care without changing PPE or performing hand hygiene. The LPN used the spoon to mix the medication and continued to manipulate the syringe and ET with the same contaminated gloves. The LPN later discarded the clogged syringe and medication mixture, obtained a new syringe and medication, and repeated similar practices of wiping the syringe, including the tip, with contaminated gloves after fluid overflow. Interviews with the LPN, the ADON (infection preventionist), and the DON confirmed that these actions were not consistent with facility expectations or standard practice, including that resident-specific items such as the graduated cylinder should not leave the room, PPE should be removed and hand hygiene performed before accessing the medication cart or exiting an EBP room, and the syringe tip that connects to the resident should not be wiped with a gloved hand. The facility’s own leadership acknowledged that the observed practices did not align with their policies and expectations. The ADON stated that staff are expected to remove PPE before exiting an EBP room and before accessing anything outside the room, especially a shared medication cart, and that resident-specific care items like the graduated cylinder should not be placed on communal surfaces. The DON similarly stated that the graduated cylinder should remain in the resident’s room, medications should be prepared either at the bedside with that cylinder or at the cart with another water source, and that staff must remove gloves and perform hand hygiene before accessing the cart and then re-perform hand hygiene and don gloves before resuming care. Both the ADON and DON stated there is no standard of practice to wipe a syringe, particularly the tip that connects to the resident, with a contaminated gloved hand. These statements, combined with the surveyor’s observations, establish that the facility did not maintain its infection prevention and control program as required by its own policies and EBP standards during ET medication administration for this resident. The surveyor’s interviews further documented that the LPN acknowledged that bringing the graduated cylinder out of the room and placing it on the cart was not standard practice and that the cylinder should not leave the room. The LPN also acknowledged that it is not standard practice to wipe off a syringe with a contaminated gloved hand prior to administering fluids or medications through an ET and that accessing items on the cart while wearing contaminated PPE is not consistent with infection control standards. Despite these acknowledgments, the observed actions during the medication pass demonstrated multiple breaches of infection control, including contamination of the medication cart, improper handling of resident-specific equipment, failure to remove PPE and perform hand hygiene before accessing shared supplies, and improper handling of the syringe tip used for ET access. These combined actions and inactions led to the cited deficiency in the facility’s infection prevention and control program.
Failure to Assess and Approve Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and approved for self-administration of medications before being left alone with physician-ordered drugs. The resident, who had diagnoses including type two diabetes mellitus, hypertension, and a history of transient ischemic attack, was cognitively intact as indicated by a perfect BIMS score. During a medication pass, an LPN brought the resident's morning medications into the room, placed them on the overbed table, and then left the room, leaving the medications unattended with the resident. The LPN later returned and administered the medications to the resident. Upon inquiry, the LPN was unsure if the resident had been approved for self-administration of medications and confirmed that she could not observe the medications while out of the room. The Director of Nursing confirmed that the resident had not been approved for self-administration. Facility policy requires that only residents approved by the interdisciplinary team may self-administer medications and that staff must observe residents consuming their medications. The failure to follow these procedures resulted in the resident being left unsupervised with medications without proper assessment or approval.
Failure to Ensure Timely Medication Administration
Penalty
Summary
The facility failed to ensure timely administration of medications for two of three residents reviewed for late medications. Record review and interviews revealed that one resident, who was cognitively intact and had diagnoses including quadriplegia and an unhealed stage three pressure ulcer, reported receiving medications either too early or late. The medications involved included Tylenol, Gabapentin, Baclofen, and Tizanidine, all of which were prescribed to be administered four times daily. The resident stated that late administration affected the timing of subsequent doses, causing them to be too close together. Audit reports from the electronic medical record showed multiple instances where medications were administered significantly outside the scheduled times, ranging from 42 minutes to over three hours late. These delays occurred repeatedly over several dates and involved various scheduled doses throughout the day and night. The medications affected were primarily for pain and muscle spasm management, and the late administration was consistently documented in the facility's records. The facility's policy, as reviewed in staff meeting documentation, required medications to be administered within one hour before or after the scheduled time unless otherwise specified by physician orders. Despite this policy, the documented medication administration times for the affected residents did not comply with the required time frames, resulting in a failure to meet the pharmaceutical service needs of the residents as outlined by facility policy and physician orders.
Failure to Prime Insulin Pen and Timely Administer Insulin
Penalty
Summary
A deficiency was identified when a nurse failed to prime a new insulin pen prior to administering insulin to a resident diagnosed with type 2 diabetes mellitus, hypertension, and a history of transient ischemic attack. The nurse admitted to not priming the pen before injection, which is contrary to both facility policy and standard practice, as confirmed by the Director of Nursing. The facility's policy requires insulin pens to be primed before use to ensure the correct dose is delivered and to avoid air in the reservoir. The resident involved was cognitively intact, as indicated by a perfect BIMS score. Additionally, the facility failed to administer insulin as ordered for the same resident on multiple occasions. Medication administration records showed that the resident's scheduled morning insulin doses were given several hours late on at least five separate dates. Interviews with nursing staff and the DON confirmed that staff are educated to administer medications within one hour before or after the scheduled time, but the audit revealed repeated late administrations outside this window.
Failure to Follow Infection Control Guidelines During Wound Care
Penalty
Summary
During wound care observations for two residents with stage three pressure ulcers, the facility failed to adhere to established infection control guidelines. For the first resident, who was cognitively intact and had a pressure ulcer on the left buttock, the Wound Care Nurse (WCN) did not remove dirty gloves, sanitize hands, or don clean gloves at appropriate intervals during the wound care process. Specifically, after assisting with repositioning and before removing the old dressing, the WCN failed to change gloves and sanitize hands. Additionally, the WCN did not sanitize hands between glove changes when handling clean wound care supplies and dressings. For the second resident, who had respiratory failure, anoxic brain injury, and an unhealed stage three pressure ulcer, similar lapses were observed. The WCN did not sanitize the overbed table before placing a clean barrier, failed to sanitize hands between glove changes, and used scissors to cut dressing material without sanitizing them beforehand. The WCN also did not open dressing supply packages prior to performing wound care, as required by infection control protocols. Interviews with the WCN, Infection Preventionist, and Director of Nursing confirmed that the observed practices did not align with facility expectations or infection control standards. The facility's wound treatment management policy did not specify infection control guidelines to be followed during wound care, contributing to the observed deficiencies.
Failure to Provide Timely and Comprehensive Pressure Ulcer Care
Penalty
Summary
A resident with a history of pressure injuries, severe cognitive impairment, and total dependence for care developed a pressure injury on the left ear. The initial discovery of the wound was not followed by a comprehensive assessment, as required by facility policy. Documentation was incomplete, with missing measurements, wound staging, and a lack of timely notification to the medical provider. The wound was first noted on 5/2, but there was no evidence of provider notification or treatment orders until 5/4. Additionally, there was confusion regarding who documented the initial finding, as the nurse listed was not present in the facility at the time. After the wound was identified, the care plan was updated to include the use of a neck pillow to offload pressure from the ear. However, multiple observations by the surveyor found the resident without the neck pillow, and staff interviews revealed a lack of awareness about this intervention. The resident was repeatedly observed with direct pressure on the affected ear, contrary to the care plan. Staff members, including CNAs and LPNs, denied knowledge of the neck pillow intervention, and there was no evidence that the intervention was consistently implemented. Despite recommendations from the wound nurse practitioner and facility wound nurse for daily wound treatments, staff continued to provide care only three times a week for several weeks. This was not in accordance with the recommended frequency, and the wound subsequently worsened, doubling in size. No additional interventions were implemented when the wound deteriorated. Comprehensive wound assessments were not consistently completed, and provider recommendations were not promptly followed. The facility failed to ensure that the resident received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols during the wound care of a resident with a facility-acquired pressure injury to the sacral area. During a surveyor's observation, CDC signage was posted outside the resident's room indicating that Enhanced Barrier Precautions (EBP) were required, including the use of gloves and gowns for high-contact resident care activities such as wound care. Despite these posted requirements, the LPN performing the wound treatment donned gloves but did not wear a disposable gown throughout the procedure. The LPN performed appropriate hand hygiene before, during, and after the wound care, but did not comply with the full PPE requirements as outlined by the CDC and facility signage. During an interview, both the Nursing Home Administrator and Director of Nursing acknowledged awareness that the LPN had not properly donned the required PPE while providing wound care. This failure to use the appropriate PPE during a high-contact procedure constituted a breach of the facility's infection prevention and control program.
Delayed Refund Following Retroactive Medicaid Approval
Penalty
Summary
The facility failed to provide a timely refund to a resident's family member after the resident's Medicaid application for long-term care services was approved retroactively. Documentation showed that the family member had made two private payments totaling $7,853 while the Medicaid application was pending. The facility's admission packet stated that if Medicaid coverage is retroactive for a period for which payment has already been made, the facility would refund or credit any excess amount within thirty days of Medicaid eligibility being established. However, interviews with the Business Office Manager and Accounts Receivable Manager revealed confusion and lack of awareness regarding the status of the refund, with the Accounts Receivable Manager only being alerted to the balance due back to the family member months after Medicaid approval. The resident was initially covered by a Medicare Advantage plan, which later discontinued skilled services, leading to the resident being considered private pay until Medicaid approval. The resident's Social Security check was used for the patient portion of payment, and the family member shared a bank account with the resident, complicating the determination of the funding source. Despite the facility's policy and the retroactive Medicaid coverage, the refund process was delayed, and staff were unclear about the procedures and status of the refund owed to the family member.
Care Plan Failed to Reflect Accurate Code Status
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the resident's current code status. According to the facility's policy, care plans are to be revised as information about residents and their conditions change. The resident was admitted with a care plan indicating full code status, but subsequent documentation in the electronic medical record, including physician orders and the facility dashboard, showed the resident was designated as do not resuscitate (DNR). The Minimum Data Set assessment indicated the resident was moderately cognitively impaired and unable to make decisions for herself, with her family member acting as the activated decision maker. Interviews with the resident's family member and the Social Services Director confirmed that the resident's code status was DNR and that the care plan did not accurately reflect this status. The Social Services Director acknowledged the inaccuracy of the care plan, and the Director of Nursing stated that her expectation was for the care plan to have the correct code status. This discrepancy between the care plan and the resident's current clinical status was identified through interviews, record review, and policy review.
Failure to Follow Infection Control Practices During Wound Care and Respiratory Treatment
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices during wound care and respiratory treatments for residents under Enhanced Barrier Precautions (EBP). During a wound care observation, the Assistant Director of Nursing (ADON) and an LPN performed hand hygiene and donned appropriate PPE before starting the procedure. However, after removing soiled gloves, the ADON failed to perform hand hygiene before donning clean gloves and proceeding with wound cleansing, which was not in accordance with the facility's hand hygiene policy. The ADON later acknowledged the missed hand hygiene step during an interview, and the Director of Nursing (DON) confirmed that hand hygiene is expected between every glove change. A review of the resident's records indicated that the resident receiving wound care had a diagnosis of hemiplegia and a stage 3 pressure ulcer, and was on Enhanced Barrier Precautions due to skin breakdown. The facility's policy and CDC guidance require strict adherence to hand hygiene and PPE use for residents with wounds or indwelling devices to prevent the spread of multidrug-resistant organisms (MDROs). In a separate incident, a respiratory therapist (RT) performed a nebulizer treatment for a resident with a tracheostomy, also under EBP, but failed to don a gown as required. Although the RT performed hand hygiene and wore gloves, the omission of the gown was contrary to both the posted EBP instructions and facility policy. The RT acknowledged the lapse during an interview, and the DON reiterated the expectation for proper PPE use during high-contact care activities for residents under EBP.
Failure to Notify POA of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's family representative and Power of Attorney (POA) of a hospital transfer for one resident. According to the facility's policy, staff are required to inform the resident, their physician, and a family member or representative of any significant events, including hospital transfers. Review of the clinical record for the resident revealed that the individual was transferred to the hospital, but there was no documented evidence that the family representative or POA was notified of this transfer. The resident in question had multiple medical diagnoses, including major depressive disorder, muscle weakness, polyneuropathy, bacteremia, gait abnormalities, diabetes with complications, and partial toe amputations. The resident's Healthcare Power of Attorney had been activated prior to the transfer, indicating that the family member was authorized to make healthcare decisions. During an interview, the Administrator confirmed that the family representative and POA were not notified of the hospital transfer, as required by facility policy.
Failure to Protect Residents from Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident abuse in two separate cases. In the first case, a resident with quadriplegia and full cognitive function reported that a registered nurse made statements to another employee outside his room, indicating a refusal to care for him and delegating his medication administration to another nurse. The resident reported experiencing emotional anguish and feeling unsafe as a result of these statements. The incident was reported to the facility's administrator, and the facility's investigation substantiated the allegation of verbal/emotional abuse. In the second case, a resident with type 2 diabetes and COPD, who was also cognitively intact, was subjected to physical abuse by a certified nursing assistant. Another staff member witnessed the CNA swat the resident on the hand after the resident accidentally grabbed the CNA's arm during repositioning, and also heard the CNA use vulgar language toward the resident. The facility's investigation substantiated the physical abuse but could not substantiate the verbal abuse. Both incidents were confirmed by the facility's administrator and director of nursing during interviews.
Failure to Timely Report Suspected Abuse Incident
Penalty
Summary
The facility failed to ensure the timely reporting of a potential abuse incident involving a resident with type 2 diabetes and COPD, who was cognitively intact as indicated by a BIMS score of 15. According to the facility's policy, staff are required to immediately report any suspicious event or injury that may constitute abuse, neglect, exploitation, or misappropriation to the Executive Director. However, a staff member witnessed a CNA swat the resident on the hand and use vulgar language during care, but the incident, which occurred at 5:30 AM, was not reported to facility administration until 7:30 PM, resulting in a 14-hour delay. Interviews revealed that the delay occurred because the staff member who witnessed the incident assumed another RN Manager, who was present during the event, had already reported it. The acting RN Manager only became aware of the incident when she started her shift and was informed by another CNA. Upon learning of the incident, the RN Manager immediately notified the Administrator, who confirmed that the alleged abuse had not been previously reported. The Administrator then reported the incident to the State Agency and local law enforcement, but confirmed that the initial reporting to administration was not timely.
Failure to Withhold Medication per Physician Order
Penalty
Summary
A resident with diagnoses of quadriplegia and orthostatic hypotension was admitted to the facility and had a physician's order for Midodrine 10 mg by mouth three times daily, to be held if the resident's systolic blood pressure exceeded 110. The facility's policy required adherence to the five rights of medication administration, including administering medications at the right time and under the correct parameters. Record review revealed that the resident received Midodrine on multiple occasions when his systolic blood pressure was above the ordered threshold, as documented in the Medication Administration Record (MAR). The resident, who was cognitively intact with a BIMS score of 15, confirmed during an interview that he had received the medication outside the prescribed parameters and expressed concern about the potential impact on his health. The DON also confirmed that these medication errors had occurred and acknowledged that medications were not administered as ordered for this resident.
Failure to Monitor Dialysis AV Fistula
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care had their Arterio-Venous (AV) Fistula monitored for bruit and thrill in accordance with professional standards of practice. The resident, who has End Stage Renal Disease among other diagnoses, did not have a medical doctor's order for monitoring the AV fistula for bruit or thrill from the end of the last recertification survey until the start of the current survey. The facility's policy and professional guidelines require regular monitoring of the AV fistula to prevent complications such as clotting or infection. The resident's care plan initially included an intervention to monitor the AV fistula for bruit and thrill, but this was canceled in April 2023. Subsequently, there was no active order or intervention for monitoring the AV fistula until December 2024, after the current survey began. Interviews with facility staff revealed a lack of clarity and consistency regarding the monitoring of the AV fistula, with some staff unsure of the frequency or method of assessment. The Director of Nursing acknowledged that the order for monitoring was not placed as an active order when the resident returned from a hospital admission. The facility identified the issue during an audit conducted over the weekend before the survey started, but the corrective action was not implemented until after the survey began. Documentation from the dialysis clinic indicated that the AV fistula was assessed on dialysis days, but not by the facility staff each shift as required.
Failure to Maintain Sanitary Conditions During Wound Care
Penalty
Summary
The facility failed to maintain a sanitary environment during wound care for a resident with a Stage 4 pressure injury to the coccyx. The resident, who was incontinent of liquid stool, did not receive incontinence care prior to a dressing change performed by an LPN. The LPN proceeded with the dressing change without cleaning the feces from the resident's buttocks and intergluteal cleft, potentially contaminating the wound dressing with fecal matter. The resident, who had a history of sepsis from the coccyx pressure injury, was totally dependent on staff for all care and had multiple medical conditions, including cardiac arrest, dysphagia, chronic respiratory failure, and diabetes. The resident's care plan included interventions for incontinence management and skin protection, but these were not followed during the observed dressing change. The LPN, assisted by the ADON, did not perform the necessary incontinence care before or after the dressing change, and the resident was left lying on a pad covered in liquid feces. The surveyor observed the dressing change and expressed concerns about the potential introduction of fecal bacteria into the wound. Despite the LPN's assertion that no feces were visible on the dressing, the surveyor highlighted the risk of contamination due to the proximity of the stool to the wound. The Nursing Home Administrator acknowledged the situation but noted that the LPN and ADON had other residents requiring wound care, which contributed to the oversight.
Deficient Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R79, had an effective discharge plan that focused on the resident's goals and safety. R79, who was admitted with multiple health issues including muscle weakness, type 2 diabetes, and chronic kidney disease requiring dialysis, expressed a desire to return home. However, the discharge care plan developed for R79 lacked measurable objectives and defined interventions consistent with the resident's needs and goals. The care plan did not identify specific barriers, education needs, equipment, or home services required for a successful discharge. During the survey, it was observed that R79 was experiencing nausea and vomiting, and there was a lack of communication among staff regarding these issues. The certified nursing assistant (CNA) and social worker (SW) involved in R79's care were not adequately informed or involved in the discharge planning process. The SW admitted that the discharge care plan was not updated regularly, and there was a lack of coordination in arranging the necessary durable medical equipment and home care services for R79's discharge. Interviews with the nursing home administrator and other staff revealed that there was a documentation issue, as changes or updates to R79's care plan were not being recorded. This lack of documentation and communication contributed to the ineffective discharge planning process, which did not adequately address R79's discharge goals and safety needs. The facility's failure to develop and implement a comprehensive discharge plan for R79 was identified as a deficiency by the surveyor.
Failure to Provide Necessary Grooming Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R50, received necessary grooming services, specifically nail trimming and face shaving, despite the resident's requests. R50, who has diagnoses including hemiplegia, hemiparesis, and cognitive communication deficit, was assessed to be dependent on staff for personal hygiene. The resident's care plan included interventions for nail care as needed and daily assistance with ADLs. However, the facility did not provide these services, citing R50's refusal of showers as the reason, even though nail trimming and shaving do not require a full bath. Observations and interviews revealed that R50 had long fingernails and had not been shaved, despite expressing a desire for these grooming services. The facility's documentation showed that R50 refused showers, but there was no documentation of refusals for nail trimming or shaving. The care plan was revised to include refusals of therapy and showers, but no interventions were implemented for the shower refusals. The facility's failure to address R50's grooming needs, despite the resident's requests and the care plan's directives, led to the deficiency noted by the surveyor.
Deficiency in Grievance Process for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, was able to voice grievances in a manner they preferred, specifically through email, and did not provide written grievance decisions as required. The facility issued a letter to residents stating that grievances could no longer be emailed, citing potential delays in response and non-compliance with state and federal requirements. This decision was not communicated effectively to R4, who was not informed of any changes allowing email grievances. R4, who has quadriplegia and anxiety, expressed that the inability to email grievances was discriminatory and violated his rights, as he could not physically write due to his condition. The facility's grievance process was found lacking in several areas. The grievance log reviewed by the surveyor did not include whether grievances were confirmed or not confirmed, nor did it provide the date written decisions were issued to R4. Additionally, R4 reported that staff members paraphrased his grievances instead of recording them verbatim, and he was not provided with copies of his grievances, which he felt could lead to misinterpretation or downplaying of his concerns. The facility's policy required that written grievance decisions include specific details, but this was not adhered to in R4's case. Interviews with facility staff revealed inconsistencies in the grievance process. The Nursing Home Administrator (NHA) and Assistant NHA provided conflicting information about the acceptance of email grievances and the process for filing them. The Assistant NHA mentioned plans to implement a grievance email address and educate residents on its use, but this had not been completed at the time of the survey. The facility's failure to provide a clear and accessible grievance process, particularly for residents with physical limitations, resulted in a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
Delayed Reporting of Alleged Verbal Abuse and Neglect
Penalty
Summary
The facility failed to report an incident of alleged verbal abuse and possible neglect involving a resident, identified as R6, to the Nursing Home Administrator and the State survey agency within the required timeframe. The incident occurred on July 10, 2024, but was not reported until July 16, 2024, six days later. The facility's policy mandates immediate reporting of such allegations to the Executive Director and relevant agencies. The resident involved, R6, has diagnoses including epilepsy, anoxic brain injury, and depression, and was assessed as cognitively intact. The incident involved a staff member allegedly yelling at R6 and refusing to change him, which was witnessed by Med Tech-E, who intervened and reported the incident to an RN Supervisor. Med Tech-E reported hearing a staff member, identified as CNA-J, yelling at R6 and refusing to change him, while R6 was found soiled. Med Tech-E intervened and later reported the incident to RN Supervisor-D, who could not recall the details when questioned by the surveyor. The Director of Nursing later confirmed that the incident was not reported to the Nursing Home Administrator or the State agency until six days after it occurred. The delay in reporting this incident constitutes a deficiency in the facility's adherence to its policy on reporting abuse and neglect.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident received prescribed medications as ordered by the physician. On July 10, 2024, during the evening medication pass, a resident did not receive their prescribed doses of Tramadol HCL 50 mg and Lorazepam 0.25 mg. The medications were not administered as the medication cart was left open and unlocked, and the medications were removed by the RN Supervisor. The facility's policy requires that medication carts be kept closed and locked when not in use, which was not adhered to in this instance. The resident involved had diagnoses including dementia, major depressive disorder, and anxiety disorder, with a BIMS score indicating severe cognitive impairment. The resident's physician orders included Lorazepam to be given twice daily for anxiety and Tramadol three times daily for pain. However, the medication administration record showed that the resident did not receive the scheduled doses on the evening of July 10, 2024. The Med Tech documented that the medications were not available, which was later confirmed by the Controlled Drug Receipt Record. The incident was further complicated by the actions of the RN Supervisor, who removed the medication cards from the cart as a purported lesson to the Med Tech. This action resulted in the resident missing their scheduled doses. The Med Tech reported the missing medications to the pharmacy and the RN Supervisor, who then returned the medication cards and instructed the Med Tech to administer the medications, albeit an hour later than scheduled. This incident was reported to the facility's administration, including the Nursing Home Administrator and Director of Nursing.
Inadequate Water Management Plan and Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in relation to its Water Management Plan (WMP). The WMP was not based on current standards of practice and lacked critical components such as identifying all locations where Legionella could grow and spread, and specifying control measures and monitoring protocols. The plan also failed to document facility-specific control measures for managing health care-acquired legionellosis, despite the presence of Legionella in the water system. The facility's response to a Legionella diagnosis included inadequate measures such as using water coolers not specifically brought in for control purposes, which were later identified as a potential bacterial concern. The facility's WMP was outdated and did not reflect the current team members responsible for its implementation. The revised plan only updated the names of the program team members without addressing the deficiencies in the plan itself. The Assistant Nursing Home Administrator admitted that the only changes made were to update the program team, indicating a lack of comprehensive review and update of the WMP. Furthermore, the Director of Maintenance was unaware of the WMP and had not received adequate training, highlighting a gap in knowledge and implementation of the infection control measures. The facility's water system was not maintained according to the documented control measures, with discrepancies in water temperature management and monitoring. The hot water system was not maintained at the temperatures specified in the WMP, and the facility failed to identify and address potential risk areas such as dead legs and infrequently used equipment. The facility's documentation and monitoring practices were inconsistent, with tasks being completed outside of the scheduled intervals and lacking specific details about the equipment and procedures involved. These deficiencies in the WMP and its implementation posed a risk of Legionella growth and spread within the facility.
Failure to Ensure Proper Use of Palm Protectors for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. The resident, who has a history of Bipolar Disorder, Idiopathic Peripheral Autonomic Neuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Hypertension, Cerebral Infarction, and Disruptive Mood Dysregulation Disorder, was observed multiple times without the prescribed palm protectors. These protectors were part of a restorative program to prevent further loss of movement and ensure proper limb alignment. During the survey, the resident was observed on several occasions without the palm protectors, despite the care plan and treatment administration record indicating they should be applied daily. The resident reported not knowing the whereabouts of the splints and was seen without them during various activities, including eating and sitting outside. The Therapy Director confirmed that the resident should be wearing the palm protectors, and there were no recent changes in the therapy recommendations. The facility's documentation, including the Treatment Administration Record and Point Click Care tasks, indicated that the palm protectors were applied, but there was no documentation of refusal by the resident. The Assistant Director of Nursing acknowledged the resident's preference not to wear the protectors due to frequent snacking but noted a lack of proper documentation regarding the refusal. This discrepancy between the documented care and the actual observations highlights a deficiency in the facility's adherence to the care plan and documentation practices.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45% during a medication pass affecting one resident. The deficiency was identified when a Licensed Practical Nurse (LPN) administered medications to a resident, including Cinacalcet and Pantoprazole, which were crushed despite being contraindicated. The facility's policy clearly states that certain medications should not be crushed due to their formulation, such as delayed-release tablets, which are designed to release medication over a sustained period. The LPN crushed all tablets except for Gabapentin and Terazosin capsules, which were opened and mixed with applesauce for administration. The resident's physician order allowed for medications to be crushed unless contraindicated, yet the LPN proceeded to crush medications that were explicitly labeled not to be crushed. The surveyor observed this error and brought it to the attention of the LPN, who acknowledged the mistake. The Assistant Director of Nursing was also informed of the medication error rate and the specific incident, but no additional information or corrective actions were provided at the time of the survey.
Failure to Label Insulin with Expiration Dates
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional standards of practice, specifically regarding the expiration dates of insulin for two residents. During an observation, it was found that insulin vials for two residents were opened and used but not dated when opened, which is against the facility's policy and professional guidelines. The policy requires that the date opened and the triggered expiration date be recorded on multidose vials, but this was not adhered to for the insulin vials observed. The surveyor observed that the insulin vials for one resident included Lantus and Humalog, both of which were opened and used without being dated. Similarly, a Humulin 70/30 Kwik pen for another resident was also opened and used without a recorded date, despite the label indicating it expires 10 days after opening. The staff, including an LPN and the Assistant Director of Nursing, were unable to provide additional information or ensure compliance with the labeling requirements during the surveyor's observations.
Failure to Report Allegation of Exploitation
Penalty
Summary
The facility failed to report an allegation of exploitation involving a resident and a staff member to the State Survey Agency. The incident began when a resident was informed by an unknown CNA about rumors of a romantic relationship and gift-giving between the resident and an LPN. This led the resident to call the police. The resident later reported to the DON that they had bought various gifts for the LPN, but the facility did not identify this as an allegation of exploitation and did not report it to the State Survey Agency as required by their policy. The resident, who was cognitively intact according to their MDS assessment, denied buying gifts or having a relationship with the LPN when interviewed by the surveyor. However, the LPN stated that the resident had become increasingly obsessed with her and had expressed a desire to buy her gifts, which she declined. The LPN also mentioned that the facility leadership was aware of the resident's fixation. Despite this, the DON did not believe the allegation of gift-giving was valid due to the resident's mental state and did not report it. The surveyor's review of progress notes and interviews with facility staff revealed that the incident was not reported to the State Survey Agency. The DON and NHA were aware of the resident's claims but did not follow the facility's policy for reporting such allegations. The facility's grievance log also did not show any grievance filed by the resident regarding this issue. The failure to report the allegation of exploitation constitutes a deficiency in the facility's compliance with state and federal regulations.
Failure to Investigate Allegations of Exploitation
Penalty
Summary
The facility failed to ensure all allegations involving potential abuse, neglect, misappropriation, injuries of unknown origin, and exploitation were thoroughly investigated for one resident. The resident, who was cognitively intact, reported to a staff member that a CNA had mentioned rumors about the resident having a romantic relationship and buying gifts for an LPN. This information was not reported to the administration, and no investigation was initiated as required by the facility's policy. The resident later called the police, which brought the situation to the administration's attention, but still, no thorough investigation was conducted into the allegations of exploitation. The Director of Nursing (DON) was aware of the resident's report of buying gifts for the LPN but did not believe the allegation would be substantiated and only spoke to the LPN without conducting a full investigation. The Nursing Home Administrator (NHA) was also aware of the resident's call to the police but did not know about the specific allegation of gift-giving. The facility's grievance log did not contain any entries from the resident regarding this issue, indicating that the grievance was not formally documented or investigated. During interviews, the DON and NHA provided inconsistent accounts of the events and actions taken. The DON admitted to not completing a thorough investigation, and the NHA directed the surveyor to speak to the Assistant Nursing Home Administrator (ANHA) when asked about the protocol for handling such allegations. The facility's failure to follow its policy and conduct a comprehensive investigation into the allegations of exploitation led to the deficiency noted in the report.
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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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