Samaritan Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in West Bend, Wisconsin.
- Location
- 531 E Washington St, West Bend, Wisconsin 53095
- CMS Provider Number
- 525165
- Inspections on file
- 24
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 28 (3 serious)
Citation history
Health deficiencies cited at Samaritan Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to protect cognitively impaired residents from sexual abuse by other residents with known histories of hypersexual and inappropriate behaviors. In one case, a CNA observed a resident crying in the dining area and later saw another resident, previously documented as sexually inappropriate with staff, with a hand inside the crying resident’s shirt grabbing the breast; the CNA had to physically remove the hand. Despite known wandering, tearfulness, and a reported history of past sexual trauma, the affected resident’s care plan was not updated with new safety measures, and behavior tracking for the aggressor was frequently incomplete, with missing entries and unclear 1:1 supervision documentation. In another case, a resident with vascular dementia, traumatic brain injury, and documented hypersexual behavior was seen in a cognitively impaired resident’s room touching the inner thigh near the pubic area, after staff had repeatedly noted this resident’s pattern of targeting and attempting to enter that same resident’s room. The care plan did not reflect the targeting behavior, and behavior monitoring for this resident was also largely incomplete, contributing to inadequate supervision and failure to prevent further inappropriate contact.
The facility, licensed for 131 beds and housing 75 residents, did not employ a qualified full-time social worker as required for facilities with more than 120 beds. The individual serving as the Social Services Designee reported not being licensed or certified as a social worker and lacking a related degree, having only prior experience working with a social worker in another facility. The NHA confirmed both the facility’s bed capacity and that the designee was not a qualified social worker, while also acknowledging awareness of the regulatory requirement for a full-time qualified social worker in a facility of this size.
The facility failed to report multiple allegations of resident-to-resident abuse to the State Agency as required by its abuse policy. In separate events, a CNA observed a severely cognitively impaired resident touch another resident’s breast, and another CNA saw a resident with dementia touch a peer’s pubic area and thigh; both CNAs intervened and reported the incidents internally, but the facility did not notify the SA. Additional unreported incidents included a resident admitting to hitting another during a dispute, a resident punching a peer after her walker was grabbed, and a resident striking at another and throwing a drink while emotionally distressed. Facility leadership acknowledged that none of these allegations were reported to the SA within the required timeframes.
The facility failed to thoroughly and accurately investigate multiple allegations of resident‑to‑resident abuse and did not ensure adequate behavior monitoring for several cognitively impaired residents. In separate incidents, CNAs reported and later confirmed observing one resident touch another’s breast and another resident touch a peer’s pubic area and thigh, but incident reports minimized or omitted the described contact and did not align with the CNAs’ signed or verbal statements. Behavior care plans were not updated with preventative safety measures, and behavior tracking records for involved residents contained numerous missing or incomplete entries. Additional verbal and physical altercations between residents were documented without comprehensive investigations, staff or witness statements, or incorporation of clear safety interventions into care plans, despite residents’ advanced dementia and severely impaired cognition.
The facility did not follow its abuse, neglect, and exploitation prevention policy requiring complete pre-employment screening when it hired an LPN without obtaining the required Department of Justice and Governmental Findings background reports. Record review later showed that these checks were only completed long after the LPN’s hire date, and interviews with the HR director and NHA confirmed that the mandated background documentation was missing from the personnel file prior to employment.
Two cognitively intact residents with significant mobility and medical needs did not receive weekly baths or showers as required by facility policy. CNA "bathing – Section GG" documentation, which was supposed to be completed every shift, was often missing, did not specify whether a shower, bath, or bed bath was provided, and did not record refusals. Review of records showed prolonged gaps where no baths or showers were documented for each resident, and separate shower documentation was either missing or not completed, while the DON confirmed that weekly showers and documentation of refusals were expected.
A resident with CHF, venous insufficiency, PVD, lymphedema, and other comorbidities had a physician order for bilateral Tubigrips to be applied each morning and removed at HS, but the resident reported staff were not consistently completing leg treatments and had not been applying the Tubigrips. During observation, a surveyor and an LPN found a loose Kerlix wrap on the resident’s lower leg dated several days earlier, despite no physician order for this dressing in the medical record. The LPN confirmed there was no order for the Kerlix and did not know why it was used, and leadership confirmed the resident should have had Tubigrips on and that any dressing should have an order, demonstrating failure to follow treatment orders and the application of an unauthorized dressing.
A resident with Alzheimer’s disease, dementia, and severe cognitive impairment, who had a known history of sexually inappropriate behavior, was care planned for paired cares with staff but not for preventing contact with other residents. Despite a prior incident of the resident touching another resident’s breast in the dining area, staff continued to seat this resident within arm’s reach of female residents, and some CNAs were unaware of any restriction on such seating. During observation, the resident repeatedly touched a CNA’s leg and then touched another cognitively impaired resident seated next to them, continuing to touch the resident’s arm and blanket after the CNA left, causing visible discomfort. The same resident also attempted to pull a surveyor closer and reached toward the surveyor’s chest, demonstrating ongoing inappropriate touching in the setting of inadequate supervision and incomplete care plan interventions.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents did not receive their ordered morning doses of spironolactone and rosuvastatin because the medications were not available in the medication cart or contingency stock. An LPN reported that prior nursing staff had not reordered the medications, noting this occurred frequently, and the DON acknowledged that medications are expected to be available and administered as ordered. These missed doses during the observed med pass resulted in a medication error rate above 5%.
A resident with an infected prosthetic knee joint and intact cognition was ordered IV vancomycin every 12 hours for several weeks following hospital discharge. Facility policy required medications to be given as ordered and any withheld or late doses to be documented with a reason. Instead, the MAR showed vancomycin scheduled at non–12-hour intervals, multiple doses marked as not administered without any progress notes, and a total of 17 days when doses were given at intervals shorter or longer than every 12 hours. Later, when the dose was adjusted and continued per infectious disease consult, the order in the MAR ended prematurely, causing a scheduled PM dose not to be given because no active order was present. Nursing staff could not recall specific reasons for the missed doses and believed they were related to lab timing, while the DON was unaware of the extent of the missed or undocumented doses.
A resident with type 2 DM, diabetic CKD, obesity, CHF, and wound care needs had an active order for a consistent carbohydrate (CCHO) diet, with the facility’s diet spreadsheet specifying a 4 oz cinnamon apple slice dessert instead of an apple crisp square. During a lunch meal, the resident was observed receiving a full apple orchard bar rather than the designated CCHO dessert. A dietary aide reported serving apple crisp bars because no cinnamon apple slices were available on the cart, and the dietary manager confirmed that a CCHO dessert should have been available and that the diet spreadsheet was to be followed.
The facility did not ensure that CNAs received the required minimum of 12 hours of annual in-service education, including dementia care and abuse prevention. Surveyors found, through staff interviews and record review, that two CNAs hired more than a year earlier had not completed at least 12 hours of in-service training during their most recent anniversary year. The NHA confirmed that these CNAs had not met the annual training requirement and acknowledged that CNAs are expected to receive at least 12 hours of in-service education each year.
The facility failed to maintain safe and palatable food temperatures during meal service, resulting in two residents receiving meals that were reported as cold. Although kitchen temperatures for items such as chicken fried steak, cheesy rice, and spinach initially met standards, delays in tray delivery to rooms and leaving the cart door open during service led to significant cooling by the time the last trays were served. A test tray checked by an RN showed entrée and side dish temperatures below 135°F, and Resident Council minutes documented repeated complaints of cold food.
Three residents experienced harm due to the facility's failure to follow physician recommendations, ensure timely imaging and consults, administer ordered antibiotics, and provide wound care according to medical orders. One resident's untreated knee infection led to hospitalization and surgery, another's wound worsened due to lack of timely treatment, and a third received wound treatments not supported by physician orders.
A resident with multiple falls and high fall risk did not have their care plan updated with appropriate interventions after each incident. Despite IDT reviews and recommendations for interventions such as auto-lock brakes and fall mats, these were not consistently implemented or documented, and the resident reported not receiving some of the suggested devices. The facility's policy for immediate intervention and care plan updates was not followed.
A resident with left-sided hemiparesis and a history of Parkinsonism and CVA required two-person assistance for bed mobility but was assisted by only one RN during care, resulting in a fall from bed and an orbital fracture. Post-fall, the facility failed to complete required neurological checks and did not notify a physician of the resident's subsequent confusion, vomiting, and swallowing difficulties. The resident died days later, with the medical examiner attributing the death to a concussion related to the fall.
Two residents' missing personal items, an iPad and a watch, were reported by their POAHCs, but the facility did not notify law enforcement or the State Agency as required. Despite internal policies mandating timely reporting of suspected misappropriation, staff and administration did not consider the incidents as misappropriation due to lack of inventory documentation or uncertainty about theft, resulting in non-compliance with federal reporting requirements.
The facility did not thoroughly investigate two separate allegations of missing personal property involving two residents, one with moderate and one with severe cognitive impairment. In both cases, the facility failed to document or conduct interviews with residents or staff as required by policy, and did not complete a thorough investigation into the reported missing items.
Three residents did not receive care and treatment as ordered by their physicians, including missed daily weights, incomplete edema assessments, and improper application and removal of TED hose and Tubigrip stockings. Staff failed to consistently follow orders for monitoring fluid retention and for the use of compression devices, resulting in residents wearing Tubigrips overnight and not receiving required assessments.
A resident with multiple serious diagnoses was observed using supplemental oxygen without a physician order or care plan addressing oxygen therapy. Staff, including a CNA and RN, were unsure about the resident's oxygen use, and the DON confirmed the absence of required documentation until it was entered during the survey. The facility's oxygen policy did not address clinical management, contributing to the deficiency.
A resident with multiple medical conditions did not receive several doses of prescribed medications, including D-Mannose, nateglinide, and pregabalin, because the medications were unavailable at the facility. Despite facility policy requiring timely administration and procedures for obtaining medications from the pharmacy, these medications were not administered as ordered over several days.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A medication cart was left unlocked and unattended in a hallway, with its computer screen displaying resident information and drawers accessible, while a resident was nearby. The responsible RN acknowledged forgetting to lock the cart when leaving to refill a water jug, contrary to facility policy requiring medication carts to be locked when not in use.
Several residents reported that meals were served cold, burned, or unpalatable, with observations confirming that food items were held below required temperatures and sometimes appeared burned. Staff were unaware of proper temperature protocols, and equipment issues contributed to the failure to maintain safe and appetizing food temperatures.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple chronic conditions and a history of pain was not assessed for pain or provided pain medication during a night shift, despite physician orders and facility policy requiring regular pain assessments and as-needed pain management. The lapse was confirmed by review of medical records and staff interview.
Three residents experienced deficiencies in medication administration, including a resident self-administering insulin without proper assessment or physician order, missing and undocumented doses of pain and other medications for another resident, and a missed injection due to lack of required lab work for a third resident. Staff failed to follow facility policy regarding medication documentation and safe administration practices.
Two residents with documented preferences for fried eggs at breakfast were not provided their preferred food item, despite repeated requests and communication with dietary staff. Instead, they were given alternative egg products, with staff citing budget, vendor supply, and staffing limitations as reasons for not fulfilling the requests. Both residents expressed dissatisfaction with the alternatives, and observations confirmed that shelled eggs were present in the facility but not used to meet resident preferences.
The facility failed to store and prepare food in a sanitary manner, affecting all 69 residents. Pre-cooked foods lacked cooling logs, and cooking temperature logs were incomplete. The three-compartment sink and sanitizer buckets were not used correctly, with sanitizer levels exceeding required PPM. The Dietary Manager admitted to filling in missing temperature logs and was unaware of proper sanitization procedures.
The facility failed to meet residents' nutritional needs by not following prescribed diet orders and serving sizes. Observations revealed incorrect serving sizes for pureed diets and non-compliance with carb-controlled and low concentrated sweets diets. Residents expressed concerns about insufficient food, and dietary staff did not adhere to diet spreadsheets, leading to improper meal service.
A facility failed to obtain court-ordered protective placement for a resident with a legal guardian, as required by state statute. The resident, admitted from a group home, had a legal guardian since 2006. Despite the requirement for protective placement documentation for residents with guardians whose stay exceeds ninety days, the facility did not have such documentation. The Social Worker acknowledged the oversight and noted the facility lacked a policy on protective placement.
The facility failed to provide three residents with timely Medicare coverage and liability notices, specifically the ABN and NOMNC forms, when their Medicare services ended. There was no documentation to confirm delivery, and interviews revealed that residents and their representatives were not informed. The facility lacked a policy and tracking system for issuing these notices.
A resident with intact cognition reported frequent interruptions during showers by staff, despite a grievance and a privacy sign being created. The communal shower room setup, with linens stored inside, led to staff entering for supplies. Some staff respected privacy by knocking, but others entered accidentally. The DON admitted not all staff were educated about the privacy sign.
The facility failed to provide safe and comfortable water temperatures for two residents, leading to complaints about cold showers and baths. Staff interviews revealed that the hot water supply was insufficient, especially when used consecutively, and the issue persisted despite some staff education. The Nursing Home Administrator was unaware of the ongoing problem, believing it had been resolved.
A resident's family member filed a grievance due to delayed lab culture results. Despite repeated inquiries, the facility failed to provide timely information or a clear resolution. The resident had intact cognition and was responsible for their healthcare decisions. The facility's grievance policy was not followed, as the family member was not kept informed throughout the process.
A resident with multiple wounds and impaired skin integrity had a pressure-relieving air mattress incorrectly set to 360 pounds instead of their actual weight of 180 pounds. The care plan lacked individualized settings for the mattress, contrary to the facility's policy. Interviews confirmed the incorrect setting, indicating a failure to provide necessary individualized care.
Two residents in the facility did not receive appropriate care to prevent urinary tract infections. One resident with severe cognitive impairment and a recent UTI was repeatedly observed with an uncovered catheter bag on the floor under their wheelchair. Another resident, on enhanced barrier precautions, had their catheter bag in contact with the floor under their bed. The facility's policy requires catheter bags to be covered and off the floor, which was not followed.
The facility failed to ensure accurate medication administration for three residents. A resident did not receive eight doses of medication due to unavailability, despite staff efforts to contact providers. Another resident missed a dose of Depakote ER because the alternative form was unavailable. An LPN administered an expired medication to a third resident and disposed of it improperly. These deficiencies highlight issues in medication availability and adherence to disposal protocols.
A resident experienced a delay in starting antibiotic treatment due to the facility's failure to ensure timely laboratory services. The resident's wound culture, collected on one date, was not sent to the lab promptly, resulting in the need for a second culture. This delay postponed the diagnosis and treatment of an infection, as confirmed by facility staff interviews.
A resident admitted to the facility did not receive their prescribed Vyvanse medication from 11/9/24 through 11/11/24 due to communication and procedural failures. The prescriber attempted to send a script to the pharmacy, but it did not go through, and the facility was not informed. The resident's family brought the medication from home, but it was not in the original container, so staff could not administer it. The resident experienced increased anxiety and was discharged against medical advice.
A resident with dementia and a stage 3 pressure ulcer did not receive the prescribed double entree for wound healing during a lunch meal. The dietary aide served a single entree despite the meal ticket indicating a double portion was required. The Food Safety Manager confirmed the oversight and acknowledged the need for training.
A resident with a history of sexually inappropriate behavior was not adequately supervised, leading to an incident where the resident engaged in inappropriate behavior with another resident who was unable to consent due to severe cognitive impairment. Despite previous incidents and documentation of inappropriate behavior, the resident was not placed under increased supervision until after the incident occurred, resulting in a finding of immediate jeopardy.
Failure to Prevent and Monitor Resident-to-Resident Sexual Abuse and Incomplete Behavior Tracking
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and to maintain an environment free from sexual abuse, particularly for cognitively impaired residents with known behavioral issues. One resident with Alzheimer’s disease and severe cognitive impairment had documented verbal and physical behaviors toward others, including potential sexual abuse, and a care plan noting a history of inappropriately grabbing staff and requiring cares in pairs due to sexually inappropriate behavior. Despite this, behavior monitoring for this resident was frequently incomplete, with large portions of behavior tracking entries missing across multiple months. The resident’s sexually inappropriate behavior toward staff was known to staff, but the facility did not consistently document or monitor these behaviors as required. On one occasion, a CNA observed a severely cognitively impaired resident crying in the dining room after supper while another cognitively impaired resident with a history of sexually inappropriate behavior appeared to be comforting the crying resident. After briefly turning away to remove meal trays, the CNA turned back and observed the second resident’s hand inside the first resident’s shirt, grabbing the resident’s right breast. The CNA had to physically remove the resident’s hand from the other resident’s breast and then returned the resident to their room. The incident was reported to nursing staff, and the crying resident remained tearful but calmed somewhat when given a stuffed animal. The crying resident had a care plan for hallucinations, agitation, wandering into other residents’ rooms, striking out, and crying unprovoked, but the care plan was not updated with any new preventative safety measures following this incident, nor did it include a care plan for past trauma, despite the activated POAHC later reporting a history of sexual assault and increased crying and wandering since the event. The facility’s investigation of the breast-touching incident documented the CNA’s account but did not result in documented preventative safety measures for either resident involved. The investigation did not address the crying resident’s frequent tearfulness, wandering, or intrusive behaviors, nor did it include safety measures to protect other residents from the sexually inappropriate behaviors of the resident who grabbed the breast. Behavior tracking for the resident with known sexually inappropriate behavior showed multiple missing or incomplete entries, and the medical record lacked complete documentation of 1:1 supervision, including missing entries for at least one day and no documentation of when 1:1 supervision was discontinued. Staff interviews confirmed awareness of the resident’s sexually inappropriate behavior toward staff and the crying resident’s frequent tearfulness and wandering, but there was no evidence that these known risks were incorporated into updated care plans or consistent monitoring. A second deficiency involved another resident with vascular dementia, behavioral disturbance, bipolar disorder, anxiety, depression, traumatic brain injury, and a documented history of hypersexual behaviors. This resident’s care plan did not include a history of inappropriate sexual behavior prior to an incident in which a CNA observed the resident in another cognitively impaired resident’s room, positioned in a wheelchair facing the other resident and touching the other resident’s private area inside the upper thigh. The CNA removed the resident from the room and reported the incident to the nurse. Staff interviews indicated that this resident had a history of sexually touching self in front of others, being verbally and physically inappropriate with female staff, and targeting and fixating on the same resident whose room the resident entered, requiring frequent redirection away from that resident. The facility’s investigation of the thigh-touching incident included written statements from staff who had observed the hypersexual resident attempting to enter the targeted resident’s room and going into other residents’ rooms, but the care plan still did not reflect the resident’s history of targeting that specific resident. Behavior tracking for this resident, which was supposed to monitor sexually inappropriate verbal or physical touch and increased wandering every shift, was also frequently incomplete, with a high percentage of missing or incomplete entries across several months. Although the resident was receiving medications for hypersexual behaviors, the lack of thorough behavior monitoring and behavior tracking, combined with the absence of care plan interventions addressing the resident’s targeting of another resident, contributed to the failure to adequately supervise and protect vulnerable residents from sexual abuse by a resident with a known history of inappropriate sexual behavior.
Lack of Qualified Full-Time Social Worker in a Large-Bed Facility
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite being licensed for 131 beds, which is more than the 120-bed threshold requiring such a position. During an interview, the Social Services Designee (SSD-G) reported having started work at the facility in June 2025 and confirmed serving as the facility’s Social Services Designee. SSD-G acknowledged not being certified or licensed as a social worker and not having a degree in a related field, stating only prior experience working in another facility alongside a social worker. In a separate interview, the Nursing Home Administrator (NHA-A) confirmed the facility’s licensed bed capacity of 131 and acknowledged that SSD-G was not a licensed or certified social worker, while also stating awareness that a facility with more than 120 beds requires a full-time qualified social worker. This practice had the potential to affect all 75 residents residing in the facility. No additional resident-specific medical histories or conditions were described in the report beyond the statement that all 75 residents in the facility had the potential to be affected by the lack of a qualified social worker.
Failure to Report Multiple Allegations of Resident-to-Resident Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report multiple allegations of resident-to-resident abuse to the State Agency (SA) as required by its Abuse, Neglect and Exploitation policy. The policy, revised 1/5/24, requires all alleged violations to be reported to the Administrator, SA, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other events. Contrary to this policy, the facility did not report several incidents involving residents with severe cognitive impairment and activated healthcare powers of attorney. One unreported incident occurred on 2/15/26 when a CNA observed a resident with Alzheimer’s disease and dementia (R6), who had a BIMS score of 2/15, place a hand inside another cognitively impaired resident’s (R1) shirt and grab her right breast while she was crying. The CNA physically removed the resident’s hand from the breast, separated the residents, and documented that the resident making contact stated he was trying to comfort the other resident and later made sexual comments toward the CNA. The CNA reported that the resident who was touched was in tears and was calmed somewhat with a stuffed animal. During interviews, facility leadership, including the Nursing Home Administrator (NHA) and DON, acknowledged that this allegation of sexual abuse was not reported to the SA. Another unreported incident occurred on 2/11/26 when a CNA observed a resident with vascular dementia and behavioral disturbance (R10), BIMS 4/15, in another severely cognitively impaired resident’s (R9) room, touching the resident’s pubic area and thigh over clothing. The CNA removed the resident from the room, reported the incident to the nurse, and later confirmed being certain of the inappropriate touching. Additional unreported incidents included a verbal dispute in which one resident stated she hit another and showed a reddened palm; an event where one resident grabbed another’s walker and was punched in the arm; and an incident in which a resident attempting to enter an elevator struck at another resident and threw orange juice, with documentation that the resident appeared emotionally distressed and attempted to hit staff. In each of these cases, facility leadership confirmed the incidents were not reported to the SA, despite the facility’s written policy requiring such reporting of alleged violations.
Failure to Thoroughly Investigate Abuse Allegations and Monitor Resident Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly and accurately investigate multiple allegations of resident‑to‑resident abuse and to ensure adequate behavior monitoring for several cognitively impaired residents. The facility’s Abuse, Neglect and Exploitation policy requires immediate investigations, identification of responsible staff, interviews of all involved parties and witnesses, and complete documentation. Despite this, for an incident in which one severely cognitively impaired resident was observed by a CNA with a hand inside another severely cognitively impaired resident’s shirt grabbing the resident’s breast, the written incident reports minimized the contact as involving the upper right extremity or arm tapping and did not match the CNA’s signed witness statement. The regional nurse consultant stated the CNA had recanted, while the CNA told the surveyor they were certain of the inappropriate contact and had to physically remove the hand. Behavior care plans for both residents were not updated with preventative safety measures, behavior monitoring documentation for both residents was largely missing or incomplete, and there was no clear documentation of the start and end of 1:1 supervision. The facility also failed to thoroughly investigate and document an allegation that one severely cognitively impaired resident touched another resident’s pubic area and thigh. A CNA reported and later confirmed to the surveyor that they directly observed the inappropriate touching, removed the resident from the room, and reported it to the nurse. However, the incident reports for both residents only documented that the alleged perpetrator was found in the other resident’s room and removed, without describing the observed touching. The regional nurse consultant reported that the CNA had recanted, in contrast to the CNA’s interview with the surveyor. Although the resident’s record called for monitoring for sexually inappropriate behavior and wandering, behavior tracking records contained a high percentage of missing or incomplete entries. Additional incidents involving verbal and physical altercations between residents were not thoroughly investigated, and appropriate safety interventions were not clearly identified or incorporated into care plans. In one event, a resident with severely impaired cognition reportedly hit another resident during a verbal dispute and showed staff a reddened palm, but the incident report attributed the redness to wheelchair self‑propulsion and listed a safety intervention of encouraging the resident to remain out of arm’s reach of others, despite the resident’s advanced dementia and memory loss. In another event, a resident grabbed another resident’s walker and was punched in the arm; the incident report identified behavioral symptoms and insufficient supervision as the root cause and listed multiple corrective concepts, yet the investigation lacked staff or witness statements, staff education, updated care plans, or documented behavior management strategies, and the resident’s care plan was not updated with safety interventions. In a further incident, a resident attempting to enter an elevator threw juice at another resident and appeared to strike them, but the facility’s investigation did not include staff or witness statements, and behavior monitoring for that resident in the same month showed multiple missing or incomplete entries.
Failure to Complete Required Background Checks Prior to Hiring Clinical Staff
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation prevention policies and procedures for one of eight sampled staff members. The facility’s written policy, dated 1/5/24, required screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property, including background, reference, and credential checks, as well as maintenance of documentation proving that such screening occurred. Despite this requirement, review of personnel records on 3/30/26 showed that an LPN hired on 8/28/25 did not have completed Department of Justice (DOJ) and Governmental Findings reports on file prior to hire. On 3/30/26, the surveyor confirmed through record review that the DOJ and Governmental Findings reports for this LPN were only completed on 3/30/26, well after the hire date. During an interview, the Director of Human Resources acknowledged that these documents were not on file and stated that they were completed on 3/30/26 because the facility did not previously have them. In a separate interview, the Nursing Home Administrator verified that the background check information for the LPN lacked DOJ and Governmental Findings reports before 3/30/26 and stated that such reports should be obtained for all staff prior to hire as part of the facility’s background check process.
Failure to Provide and Document Weekly Bathing for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document scheduled bathing or showering assistance for two residents who required help with activities of daily living. The facility’s ADL policy dated 5/7/20 states that, in accordance with the comprehensive assessment and resident needs and choices, the facility will provide hygiene care including bathing. Resident 5, admitted with diagnoses including a right lower leg fracture, morbid obesity, and type 2 diabetes, had an MDS dated 3/20/26 showing intact cognition with a BIMS score of 15/15. During an interview on 3/30/26, this resident reported that showers were not always completed on the scheduled day and that it had been three weeks since a proper shower. Review of the CNA “bathing – Section GG” task documentation, which was supposed to be completed every shift, showed that charting was not done every shift, did not specify the type of bathing provided or refusals, and indicated that the resident did not receive a shower between 2/6/26 and 2/20/26. Separate shower documentation for the prior 30 days was absent from the medical record. Resident 2, admitted with diagnoses including chronic pain syndrome and obesity, also had intact cognition with a BIMS score of 15/15 on an MDS dated 12/29/25. An ADL care plan initiated 12/24/25 documented that this resident was non-ambulatory and required an EZ stand with assistance of two staff for transfers. Review of the same CNA “bathing – Section GG” documentation for this resident showed that charting was again not completed every shift, only reflected “NO” or a number indicating level of assistance, and did not identify whether a shower, bath, or bed bath was provided or if the resident refused. The documentation indicated that this resident did not receive a bath or shower between 1/18/26 and 1/29/26 and again between 2/1/26 and 2/20/26. During an interview on 3/30/26, the DON stated that showers should be provided weekly and refusals documented, and acknowledged the discrepancy between where CNAs reported documenting showers and the documentation actually provided, confirming that the residents had periods longer than seven days without a documented bath or shower.
Failure to Follow Compression Therapy Orders and Use of Unauthorized Leg Dressing
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for compression treatment and the provision of an unauthorized dressing for one resident. The resident, admitted with multiple diagnoses including type 2 diabetes with diabetic chronic kidney disease, CHF, venous insufficiency, PVD, morbid obesity, polyneuropathy, and lymphedema, had a care plan for impaired circulation related to CHF and venous insufficiency. A physician order dated 12/4/25 directed the use of bilateral Tubigrips, sized per leg measurements, to be applied every morning and removed at bedtime for lymphedema. During record review and interviews, the resident reported that staff did not always complete leg treatments and stated they had not seen the Tubigrips in a while and that staff had not been applying them. An LPN also reported not seeing the Tubigrips in the resident’s room that morning. In addition, during observation on 3/30/26, the surveyor and an LPN noted a loose piece of Kerlix wrap around the resident’s left upper ankle, dated 3/26/26. The resident’s medical record did not contain a physician order for a Kerlix dressing to the left lower extremity. The LPN confirmed there was no order for this dressing and was unsure why Kerlix had been used. The DON and NHA later confirmed that the resident should have had Tubigrips on and that any refusal should be documented, and also confirmed that an order should be in place for any dressing applied. These findings show that the facility did not ensure physician orders for Tubigrips were consistently followed and that treatment in the form of a Kerlix dressing was provided without a corresponding physician order.
Failure to Prevent Recurrent Sexually Inappropriate Contact Through Adequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement appropriate interventions to prevent recurrent sexually inappropriate contact by one resident toward others. The resident had Alzheimer’s disease, dementia, severe cognitive impairment with a BIMS score of 3/15, and an activated POA for healthcare. The care plan included an intervention for cares in pairs due to sexually inappropriate behavior toward staff, but it did not include interventions to prevent the resident from inappropriately touching other residents, despite a documented incident in which the resident touched another resident’s breast in the dining room. The facility’s abuse, neglect, and exploitation policy required identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or abuse, as well as staff training on behavioral symptoms that increase the risk of abuse. On the survey date, the resident was observed seated in a wheelchair in the dining/lounge area between a CNA and another resident with severe cognitive impairment (BIMS 0/15) and an activated POA for healthcare. The resident repeatedly reached out and touched the CNA’s leg and then touched the adjacent resident, with the CNA redirecting the resident’s hand and verbally instructing the resident not to touch. After the CNA was called away, the resident continued to touch the other resident’s arm and blanket, causing the other resident to grimace and attempt to pull away, until another CNA arrived and removed the other resident. Staff interviews revealed that some CNAs were unaware that the resident should not be seated within arm’s reach of female residents and reported that the resident had previously been on 1:1 supervision and had a history of inappropriately touching staff. The resident was also observed by the surveyor attempting to pull a surveyor toward them and reaching toward the surveyor’s chest, further demonstrating ongoing sexually inappropriate touching behavior in the absence of effective preventive interventions and supervision.
Medication Unavailability Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, resulting in a calculated error rate of 6.8% during a medication pass observed by surveyors. During 29 medication administration opportunities, 2 errors occurred when ordered morning medications were not administered because they were not available in the medication cart or contingency stock. For one resident with acute on chronic diastolic heart failure and intact cognition, the LPN did not administer the ordered morning dose of spironolactone 12.5 mg, as the medication was not present and had not been reordered. The facility’s policy required medications to be administered safely, timely, and in accordance with orders, including within one hour of the prescribed time. A second resident, who had hyperlipidemia, atherosclerosis, moderate cognitive impairment, and an activated POA for healthcare, also did not receive the ordered morning dose of rosuvastatin 20 mg because the medication was unavailable in both the medication cart and contingency stock. In interviews, the LPN reported that the previous nurse had not reordered these medications and stated that this situation occurred often. The DON confirmed that medications should be available and that staff should provide medications as ordered. These observed failures to have medications available and to administer them as prescribed led to the identified medication errors and the facility’s medication error rate exceeding 5%.
Failure to Administer and Document IV Vancomycin as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to IV vancomycin administration. The resident was admitted after a knee replacement with an infected prosthetic joint and had diagnoses including hemiplegia, history of stroke, epilepsy, and chronic pain. Hospital records, including an infectious disease note and discharge summary, directed continuation of IV vancomycin for six weeks at 1250 mg every 12 hours via PICC line. The facility’s policy required medications to be administered as ordered and that any withheld, refused, or unscheduled doses be documented with a reason. However, the resident’s February MAR showed vancomycin scheduled at 9:00 AM and 6:00 PM (9 and 15 hours apart) instead of every 12 hours as ordered. On multiple dates, doses were marked as not administered (coded “9”) by nursing staff without any corresponding progress notes explaining why the doses were held. Further record review showed that on one date the PM dose was not given, on another date both AM and PM doses were not given, and on a third date the AM dose was not given, all without documented rationale. The vancomycin dose was later decreased to 1000 mg and rescheduled to 9:00 AM and 9:00 PM, but there were 17 days in which doses were administered at intervals of less or more than 12 hours. An infectious disease consult subsequently ordered continuation of vancomycin 1000 mg every 12 hours with an estimated end date later in the month, yet the MAR showed the order ended after the AM dose on one date, resulting in the resident not receiving the scheduled PM dose because there was no active order in the MAR. Vancomycin trough levels during this period were within or slightly above the therapeutic range, and staff interviews revealed that nurses believed doses were held while awaiting lab results, despite no documentation and despite the DON being unaware of the total number of missed or undocumented doses.
Failure to Provide Prescribed Consistent Carbohydrate Dessert
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed consistent carbohydrate (CCHO) diet dessert to one resident. The facility’s policy, dated 3/12/18, outlined the process for entering diet orders and ensuring accuracy in the electronic health record (EHR). The resident, admitted in late 2025, had diagnoses including type 2 diabetes with diabetic chronic kidney disease, obesity, CHF, and wound care needs, and had care plans addressing type 2 diabetes mellitus and nutritional problems related to diet restrictions. The resident had an active order for a CCHO diet. On review of the facility’s diet spreadsheet, surveyors noted that residents on a CCHO diet were to receive 4 ounces of cinnamon apple slices instead of an apple crisp square. During a lunch meal observation, the surveyor saw that the resident on a CCHO diet received a full square of an apple orchard bar rather than the designated CCHO dessert. When interviewed, the dietary aide stated that apple crisp bars were provided because there were no cinnamon apple slices on the cart for the lunch meal. The dietary manager confirmed that the dietary aide should have had an appropriate CCHO dessert available and that the diet spreadsheet was to be followed.
Failure to Provide Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) received the required minimum of 12 hours of in-service training during their most recent anniversary hire year, including education in dementia care and abuse prevention. Record review on 4/13/26 showed that CNA-Z, hired on 6/14/21, had not completed at least 12 hours of educational training during the most recent anniversary year. On the same date, review of records for CNA-AA, hired on 10/23/23, also showed that this CNA had not completed the required 12 hours of in-service education during the most recent anniversary hire year. In an interview on 4/13/26 at 3:45 PM, the Nursing Home Administrator confirmed that both CNAs had not met the 12-hour annual in-service education requirement and acknowledged that CNAs are expected to receive at least 12 hours of in-service education per year. No resident-specific medical histories or conditions were described in the report, and the deficiency centers on the facility’s failure to provide and document the mandated annual in-service training hours for the identified CNAs.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were served at a palatable and safe temperature, as required by its Safe Food Handling policy and the FDA Food Code. The policy directed dining services staff to use food preparation techniques that minimize the time food is held below 135°F or above 41°F. During a meal service observation, dietary staff initially measured appropriate temperatures in the kitchen for the regular diet entrée of chicken fried steak (164°F), cheesy rice (160°F), and spinach with onions (167°F) before service. However, residents eating in the dining room were served first, and trays for residents who chose to eat in their rooms were plated afterward, with the last cart not reaching the fourth floor until later in the meal period. The cart door remained open while trays were passed, and the last tray was not served until 12:45 PM. Two cognitively intact residents reported receiving food that was not hot. One resident, admitted on a recent date with an admission MDS showing a BIMS score of 15/15, stated that their bite-sized food “could be hotter.” Another resident, with an admission MDS BIMS score of 14/15, reported that their regular diet meal was cold and that it was always cold. Resident Council minutes documented complaints of cold food at meetings held on two separate dates. A test tray taken from the last cart on the fourth floor and checked with a digital thermometer by an RN showed the chicken fried steak with gravy at 126°F, cheesy rice at 130°F, and spinach with onions at 130°F, all below the 135°F standard for food service and palatability. These observations and interviews demonstrate that the facility did not consistently maintain food temperatures during tray line and delivery to residents, resulting in meals being served below required temperatures.
Failure to Provide Timely and Appropriate Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent the worsening of non-pressure related wounds for three residents. One resident with a history of left total knee arthroplasty experienced ongoing pain, redness, and swelling in the left knee and lower leg. Despite repeated recommendations from wound care and medical staff for an MRI and orthopedic consult, the facility did not ensure these were completed. The MRI was canceled multiple times due to insurance concerns, and no further assistance was provided to obtain the imaging or consult. The resident received multiple courses of oral antibiotics without resolution, and a subsequent course of antibiotics was not administered as ordered. The resident was eventually hospitalized with a septic joint, underwent surgical intervention, and returned to the facility with ongoing pain and loss of function. Another resident with a history of basal cell carcinoma removal and multiple sclerosis developed a wound on the right lower extremity. An initial treatment order was entered and discontinued on the same day, and no new order was entered, resulting in a lack of assessment or treatment for nearly two weeks. During this period, the wound deteriorated and increased in size. The wound was only reassessed and treated after the resident requested to see the wound clinic, at which point antibiotics and appropriate wound care were initiated. A third resident with multiple comorbidities, including sepsis and systemic sclerosis, received wound care treatments that were not supported by physician orders. Staff applied lidocaine, gentian violet, and Iodosorb to wounds without corresponding medical orders, and substituted treatments when supplies were unavailable without documented physician approval. These actions were observed during wound care and confirmed by staff interviews, indicating a lack of adherence to established protocols for wound management and physician-directed care.
Removal Plan
- Identify other residents with current wounds and assess for signs/symptoms of infection, including redness, warmth, pain and swelling, and ensure referrals, consults, imaging, lab work, antibiotics, and wound treatments are administered.
- Educate licensed nursing staff on the facility's wound management policy and protocol to follow-up on skin issues as well as updating/documenting dressing changes.
- Review all wound orders by the DON/designee to ensure accuracy and follow-up.
- Conduct skin audits. Provide education when indicated.
Failure to Update Care Plan and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that adequate assistive devices and supervision were in place to prevent falls for a resident with a history of multiple falls. Despite the resident being identified as high risk for falls due to recent admission, prior falls, and use of psychotropic, pain, and narcotic medications, the care plan was not updated with appropriate interventions after each fall. The resident experienced falls on several occasions, including incidents where the wheelchair brakes were not locked, the resident rolled out of bed, and dizziness led to a fall resulting in a head injury. Although the interdisciplinary team (IDT) reviewed each fall and discussed possible interventions such as auto-lock brakes, fall mats, and bolsters, these interventions were not consistently implemented or documented in the resident's care plan. Interviews and record reviews revealed that the resident did not receive some of the recommended interventions, such as bolsters or a fall mat, and the care plan was not updated to reflect new or revised interventions after each fall event. The facility's policy required immediate interventions and care plan updates following falls, but these steps were not followed. The President of Clinical Operations confirmed that the care plan should have been updated after new interventions were determined, acknowledging that this did not occur for the resident in question.
Failure to Provide Adequate Supervision and Post-Fall Monitoring for Resident with Hemiparesis
Penalty
Summary
A resident with a history of Parkinsonism, cerebrovascular accident (CVA) resulting in left-sided hemiparesis, and a stage 4 sacral pressure ulcer required assistance for bed mobility. During morning care, a registered nurse (RN) was providing wound and incontinence care when the resident, who was positioned on the left side, rolled out of bed after the RN turned away to retrieve a brief. The resident struck their head on the wall and then the metal bed frame, resulting in an orbital floor blowout fracture with herniated extraconal fat. The care plan indicated the resident required assistance from two staff for bed mobility, but only one staff member was present at the time of the incident. There was confusion among staff regarding the care plan, with some believing the two-person assistance requirement was implemented only after the fall, despite documentation indicating it was in place prior to the incident. Following the fall, the facility did not ensure thorough post-fall monitoring or neurological checks as required by policy. The monitoring order was not consistent with the 72-hour minimum, and neurological checks were incomplete or missing for several shifts. The resident exhibited symptoms consistent with a concussion, including intermittent confusion, vomiting, and swallowing difficulties, as documented by hospice staff and family. Despite these changes in condition, there was no evidence that a physician was notified or that the care plan was updated to reflect the resident's deteriorating status. Interviews with staff and review of records revealed that the RN did not position the resident's flaccid side appropriately, contributing to the fall. The facility's investigation also found that staff were not fully aware of or did not follow the care plan interventions for bed mobility. Additionally, there was a lack of communication and documentation regarding the resident's post-fall symptoms and changes in condition, including episodes of vomiting and increased confusion. The medical examiner determined the resident's death was accidental, caused by a concussion in the setting of Parkinsonism, with the orbital fracture and CVA history as significant contributing conditions.
Removal Plan
- Reviewed, screened, and updated care plans for residents with diagnoses of hemiparesis and falls related to bed mobility.
- Met with Hospice staff to ensure effective communication regarding changes in condition. Updates should be given to the DON or designee before Hospice staff leave the building.
- Educated facility and agency staff on bed mobility, post-fall assessments, and changes in condition.
- Initiated bed mobility and change in condition competencies to ensure staff follow proper techniques and protocols. Ad hoc education to be provided immediately when indicated.
Failure to Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to develop and/or implement policies and procedures to ensure the timely reporting of suspected misappropriation of resident property, as required by section 1150B of the Act. In two separate cases, grievances were filed by the Power of Attorney for Healthcare (POAHC) for two residents regarding missing personal items: an iPad and a watch. In both instances, the allegations of misappropriation were not reported to law enforcement or the State Agency (SA), despite the facility's own policy requiring such reporting within specified timeframes. In the first case, a resident with moderate cognitive impairment and a history of malignant neoplasm of the bladder, secondary neoplasm of the bone, and toxic encephalopathy reported a missing iPad. The resident's POAHC indicated the iPad was present before a hospital stay but missing upon return. The facility's social worker acknowledged receiving the grievance and multiple communications with the POAHC, but the incident was not reported to law enforcement or the SA. The Nursing Home Administrator (NHA) stated that the missing iPad was not considered misappropriation because it was not on the resident's inventory list and staff did not recall seeing it. In the second case, a resident with severe cognitive impairment and a diagnosis of dementia and neurocognitive disorder with Lewy bodies was reported by the POAHC to have a missing watch after the resident's death. The facility offered reimbursement, which was declined due to the watch's sentimental value. The grievance officer confirmed the facility's investigation did not include reporting the incident to law enforcement or the SA. The NHA indicated the missing watch was not considered misappropriation because the POAHC was unsure if it was stolen. In both cases, the facility did not follow its own policy or federal requirements for reporting suspected misappropriation.
Failure to Investigate Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of property for two residents. In the first case, a resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC) reported a missing iPad, which was also reported by the POAHC. The iPad was not listed on the resident's inventory sheet, but the family indicated it had been brought in. The facility's response was limited to discussing the issue in a daily standup meeting and instructing departments to ask staff if they had seen the iPad. However, there was no documentation that the resident, other residents, or staff were interviewed, and the facility confirmed that these interviews were not completed. In the second case, a resident with severe cognitive impairment and an activated POAHC was reported to have a missing watch after their passing. The POAHC filed a grievance, and the facility offered reimbursement, which was declined due to the watch's sentimental value. The facility's investigation consisted of housekeeping and nursing staff searching for the watch, but there was no documentation of interviews with other residents or staff. The facility confirmed that a thorough investigation, including interviews, was not completed for this allegation either.
Failure to Follow Physician Orders for Compression Devices and Monitoring
Penalty
Summary
Three residents did not receive care and treatment in accordance with physician orders, as observed through record review, staff and resident interviews, and direct observation. One resident with a history of left total knee arthroplasty, cellulitis, diabetes, and congestive heart failure (CHF) had orders for daily weights and edema assessments to monitor for fluid retention, as well as orders for the application and removal of TED hose and Tubigrip bandages. Staff failed to obtain and document daily weights on specific days and did not consistently perform or document edema assessments as ordered. Additionally, the resident did not have TED hose orders upon admission despite wearing them, and after an order change to Tubigrips, staff continued to use TED hose instead of following the updated order. Two other residents with diagnoses including CHF, atrial fibrillation, chronic kidney disease, muscle wasting, and vascular dementia had physician orders for Tubigrip stockings to be applied in the morning and removed in the evening. Observations and interviews revealed that staff did not consistently remove the Tubigrips at night as ordered, resulting in the residents wearing them overnight. Both residents and their representatives reported that staff sometimes forgot to remove the Tubigrips, and this was corroborated by staff interviews and direct observation. The facility lacked a written policy for the application and removal of TED hose and Tubigrip stockings, relying solely on medical orders. The Director of Nursing confirmed that staff did not follow the care plans and medical orders regarding daily weights, edema assessments, and the application and removal of compression devices for the affected residents.
Failure to Provide Necessary Respiratory Care and Documentation
Penalty
Summary
A resident with diagnoses including malignant neoplasm of the bladder, secondary neoplasm of the bone, toxic encephalopathy, and osteoporosis with pathological fractures was observed to have an oxygen concentrator at the bedside. The resident had moderate cognitive impairment and an activated Power of Attorney for Health Care. Despite requiring supplemental oxygen following a change in respiratory status, there was no physician order for oxygen therapy or a care plan addressing oxygen use in the resident's medical record at the time of the survey. Staff interviews confirmed uncertainty regarding the resident's oxygen use, and the CNA care plan did not include oxygen therapy. The Director of Nursing provided an undated oxygen policy focused on safety and fire prevention but confirmed the absence of a comprehensive oxygen therapy policy. During the survey, the DON located an order from the hospice provider for oxygen therapy, but it was only entered into the medical record during the survey process. Additionally, a standing order for emergency oxygen was also entered into the record during the survey. Prior to these entries, the resident's need for oxygen was not supported by a current order or care plan, and staff were not consistently aware of the resident's oxygen requirements.
Failure to Provide Timely Pharmaceutical Services Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident. The resident, who had diagnoses including left total knee arthroplasty, osteoarthritis, cellulitis, and diabetes, was admitted with intact cognition and was responsible for their own healthcare decisions. Physician orders were in place for D-Mannose, nateglinide, and pregabalin, with specific dosages and administration times. However, a review of the Medication Administration Audit Report revealed multiple instances where these medications were not administered as ordered due to unavailability. Specifically, D-Mannose, nateglinide, and pregabalin were missed on several occasions over a period of days, with documentation indicating the medications were not available at the facility at the required times. The facility's policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time unless otherwise specified. Despite this, the medications were not provided to the resident according to physician orders. During an interview, the Director of Nursing confirmed that the pharmacy is expected to deliver medications when ordered and that staff should contact the pharmacy with a stat order if medications are not delivered, indicating that the established procedures for obtaining medications were not followed in these instances.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the 400 North unit was observed left unlocked and unattended, with an open computer screen displaying resident information. The drawers of the cart faced the hallway, and a resident was seen self-propelling in a wheelchair nearby. The agency RN responsible for the cart confirmed that it should have been locked and the computer turned off, but stated they forgot to do so when leaving to refill a water jug. The facility's policy requires all medication storage compartments, including carts, to be locked when not in use and not left unattended if open or accessible. The DON also confirmed that medication carts should be locked when unattended.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable, safe, and appetizing temperatures for four of six sampled residents. Multiple residents and a resident representative reported that hot and cold foods were not always served at appropriate temperatures, with some describing the food as cold, mushy, burned, or unpalatable. During meal observations, surveyors noted that food items such as sweet potatoes appeared burned and that several residents' meals contained blackened edges. Additionally, one resident reported that cold and hot foods were placed together under the same cover, resulting in cold food becoming warm and unappetizing. Temperature checks conducted by the surveyor revealed that food items on the steam table, including steamed rice, sweet and sour chicken, and broccoli, were held well below the required minimum hot holding temperature of 135°F. The dietary aide responsible for monitoring food temperatures was unaware of the minimum holding requirements or the necessary steps to take when temperatures were inadequate. The Food Service Director confirmed that while staff were expected to take holding temperatures prior to serving, temperatures were not routinely monitored at the end of meal service, and there were known issues with the steam rollers not maintaining proper temperatures.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Assess and Manage Pain During Night Shift
Penalty
Summary
A resident with diagnoses including COPD, congestive heart failure, anxiety disorder, and failure to thrive, who was cognitively intact and responsible for their own healthcare decisions, was not assessed for pain or provided pain medication during a specific night shift. The facility's policy required pain assessments and appropriate pain management based on comprehensive assessment and resident choice. The resident had physician orders for as-needed hydrocodone-acetaminophen and acetaminophen for pain, and a specific order for pain assessments every shift for three days. Review of the medical record showed that while pain assessments were documented for all other shifts, there was no pain assessment or administration of pain medication during the night shift in question. The resident later reported to staff that they did not receive pain medication that night, and the Medication Administration Record confirmed that the first dose of pain medication was given the following morning for severe pain. The Director of Nursing confirmed that the resident was not assessed for pain and did not receive pain medication during the identified night shift.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the accurate administration of medications for three residents. One resident with diabetes and end-stage renal disease self-administered Tresiba insulin without a physician's order or a self-administration assessment, and there was no care plan in place for self-administration. Additionally, a significant quantity of the resident's insulin was unaccounted for, and staff allegedly borrowed insulin from another resident's supply for administration, contrary to facility policy and safe medication practices. Another resident with multiple chronic conditions, including COPD, pulmonary embolus, and chronic pain, did not receive several doses of prescribed medications, including controlled substances and pain medications. The resident reported frequently having to request missing medications, and the medical record lacked documentation explaining whether the medications were administered, refused, or unavailable. The facility's medication administration policy was not followed, as staff failed to document missed doses or provide required progress notes. A third resident with moderate cognitive impairment and multiple serious diagnoses, including cirrhosis and chronic kidney disease, did not receive a scheduled Epoetin Alfa injection as ordered. The medication was withheld due to a missing hemoglobin level, but there was no order obtained for the necessary lab work, and the omission was not properly documented. These deficiencies were identified through observation, staff and resident interviews, and record review, and they demonstrate failures in medication administration, documentation, and adherence to facility policy.
Failure to Honor Resident Food Preferences for Breakfast
Penalty
Summary
The facility failed to honor the food preferences of two residents by not providing their preferred breakfast item of fried eggs, despite these preferences being documented and communicated to dietary staff. One resident, who was cognitively intact and had a history of chronic medical conditions, regularly requested fried eggs for breakfast but was repeatedly told by the dietary manager that shelled eggs could not be provided due to vendor supply issues and facility budget constraints. The resident expressed dissatisfaction with the alternative options, such as liquid eggs, and stated that discussions with the dietary manager had not resulted in their preference being met. Observations in the kitchen revealed that shelled eggs were present but reserved for specialty items, and not used to fulfill resident breakfast preferences. Another resident, with moderately impaired cognition and multiple chronic diagnoses, also had a documented preference for fried eggs at breakfast but did not receive them. This resident reported that requests for fried eggs were denied due to cost and availability, and expressed dissatisfaction with the alternative scrambled eggs provided. Interviews with dietary staff confirmed that while shelled eggs were ordered, they were not served to residents as requested due to budget limitations, vendor supply issues, and staffing constraints. Meal tickets for residents who preferred fried eggs were changed to "if available," but the facility did not provide the preferred item, resulting in unmet resident preferences.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 69 residents. During a kitchen tour, it was observed that pre-cooked foods such as pureed vegetables, fish, macaroni and cheese, and others were stored without a cooling log. The Dietary Manager (DM) confirmed that these foods should have been cooled using an approved method and documented to ensure safe consumption. The facility's policy and the FDA Food Code require that cooked foods be cooled to specific temperatures within a set timeframe, but this was not adhered to. Additionally, the facility did not consistently monitor and document the temperatures of cooked foods. The cooking temperature logs for December 2024 and January 2025 were missing multiple entries for supper meals. The DM admitted to filling in missing temperatures after the fact and acknowledged that the process of documenting cooked food temperatures was not consistently followed by the PM staff. This lack of documentation and adherence to cooking temperature guidelines could compromise food safety. The facility also failed to properly use the three-compartment sink and sanitizer buckets. The sanitizer testing logs showed PPM levels above the required 200 for several days, and some logs were missing entries. The DM was unaware of the correct PPM levels and water temperature requirements for the sanitizing solution, indicating a lack of understanding among staff regarding proper sanitization procedures. This oversight in maintaining proper sanitization levels could lead to unsanitary conditions in food preparation areas.
Failure to Adhere to Prescribed Diet Orders and Serving Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to prescribed diet orders and serving sizes. This deficiency was observed in five residents, where residents on pureed diets did not receive the correct serving sizes for meals on specific dates. Additionally, residents on carb-controlled and low concentrated sweets diets did not receive their meals as ordered. For instance, one resident's meal ticket indicated they should receive double portions and specific diet items, but these were not provided during meal services. The surveyor observed several discrepancies during meal services, including the use of incorrect scoop sizes for serving pureed foods and desserts. Dietary aides were noted to serve full portions of desserts to residents on restricted diets and did not follow the specified serving sizes outlined in the diet spreadsheets. One resident was served a pork roast instead of the ground meat as per their diet order, and another resident expressed concerns about not receiving enough food, feeling weak and hungry as a result. Interviews with residents and dietary staff revealed that the facility did not have enough servings to meet residents' requests for more food, and there was a lack of adherence to the diet spreadsheets that guide meal preparation and serving sizes. The dietary manager confirmed that all staff have access to these spreadsheets, which are intended to ensure compliance with diet orders, but the recommended scoop sizes were not consistently used during meal service.
Failure to Obtain Court-Ordered Protective Placement for Resident with Guardian
Penalty
Summary
The facility failed to ensure that a court-ordered protective placement was obtained for a resident with a legal guardian, as required by state statute. The resident, who had a legal guardian since 2006 and a successor guardian appointed in 2023, was admitted to the facility from a group home. Despite the requirement for protective placement documentation for residents with guardians whose stay exceeds ninety days, the facility did not have such documentation in the resident's medical record. During the survey, the Nursing Home Administrator was unable to provide the necessary protective placement paperwork, and the Social Worker acknowledged that the facility had not obtained it. The Social Worker indicated that the Admissions Coordinator is responsible for obtaining the paperwork upon admission, and the Social Worker ensures annual reviews are received from the county. However, the facility did not have a policy regarding protective placement, and the Social Worker admitted that they had contacted the county to initiate the process only after the surveyor's inquiry.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide three residents with the necessary Medicare coverage and liability notices, specifically the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) and the Notice of Medicare Non-Coverage (NOMNC) forms, in a timely manner. Residents R13, R15, and R168 did not receive these forms when their Medicare services ended, and there was no documentation to confirm that the forms were delivered or that the residents or their representatives were informed. The facility's process involved leaving forms in residents' rooms or sending them via mail, but there was no system to track whether the forms were actually sent or received. Additionally, the facility lacked a policy regarding the issuance of Medicare coverage/liability notices. Interviews with the residents and their representatives revealed that they were not verbally informed about the termination of Medicare services, nor did they receive the forms by mail. The Minimum Data Set Coordinator (MDSC) responsible for distributing these forms could not provide evidence of their delivery. The Nursing Home Administrator acknowledged that notifications should be mailed and documented, but this was not done. The absence of a formal policy and documentation process contributed to the deficiency, leaving residents uninformed about their Medicare coverage status and potential financial liabilities.
Privacy Breach During Resident Showers
Penalty
Summary
The facility failed to ensure privacy for a resident during shower times, leading to a deficiency in maintaining confidentiality and dignity. The resident, who has intact cognition and is responsible for their healthcare decisions, reported that staff frequently entered the shower room while they were showering, despite a grievance being filed. The resident had a sign created to indicate when they were using the shower, but staff were not adequately informed about the sign, resulting in continued interruptions. Observations and interviews revealed that the shower room was communal, with linens stored in a closet within the room, which contributed to staff entering during the resident's shower time. Some staff members were aware of the need for privacy and attempted to respect it by knocking and asking for permission to enter, while others admitted to entering the room accidentally. The Director of Nursing acknowledged that not all staff had been educated about the new privacy sign, and there was no documentation of staff education regarding this matter.
Deficiency in Providing Safe Water Temperatures
Penalty
Summary
The facility failed to ensure the provision of safe and comfortable water temperatures for two residents, R7 and R16, among 23 sampled residents. R7, who has intact cognition and is responsible for their healthcare decisions, reported multiple instances of not having warm water while showering on the fourth floor. The issue was attributed to high hot water usage by the laundry and kitchen, with a resolution expected by August 2025. R16, also with intact cognition, experienced a bath with cool water, which was against their care plan that advised avoiding exposure to extreme temperatures. The facility's grievance records showed several complaints about cold water, with the latest grievance indicating a 13-minute wait for warm water. Staff interviews revealed that the facility's hot water supply was insufficient, especially when multiple residents used it consecutively. CNA-O confirmed running out of warm water during a bath for R16 and rinsing them with cool water. CNA-T and RNM-L acknowledged the recurring issue, with RNM-L receiving weekly complaints in late 2024. Despite some staff education on water usage, the problem persisted, and the Nursing Home Administrator was unaware of the ongoing issues, believing the problem had been resolved.
Failure to Resolve Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance filed by a family member of a resident, identified as R25, regarding the delay in obtaining lab culture results. R25 had a lab culture obtained, and over several days, the family member repeatedly contacted the facility for the results but was not provided with them. The family member filed a grievance, but the facility only informed them that the issue was resolved without providing an explanation or details on the resolution. R25 was admitted to the facility with diagnoses including T12 compression deformity, chronic kidney disease, and anemia, and had intact cognition as indicated by a BIMS score of 13 out of 15. The facility's grievance policy requires prompt resolution and communication with the resident or their representative, which was not adhered to in this case. The Nursing Home Administrator and Director of Nursing acknowledged the grievance and mentioned a process change to prevent future delays, but there was no documentation of this change or staff education.
Failure to Individualize Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with impaired skin integrity and multiple wounds. The resident, who was bed bound and receiving hospice services, had a pressure-relieving air mattress that was incorrectly set to 360 pounds, despite the resident's actual weight being 180 pounds. This incorrect setting was not individualized in the resident's care plan, which lacked specific instructions for the air mattress settings. The resident's medical record indicated multiple diagnoses, including pressure-induced deep tissue injury, chronic venous ulcers, and a chronic ulcer of the buttocks. The facility's Wound Care Prevention and Program Management policy required interventions to be documented and individualized based on risk factors, but this was not adhered to in the resident's case. Interviews with the Director of Nursing and a Registered Nurse Manager confirmed the air mattress was set incorrectly, highlighting a failure to follow the facility's policy and provide necessary individualized care for the resident's condition.
Failure to Prevent Catheter-Associated UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for two residents, R15 and R368. R15, who has severe cognitive impairment and a history of a recent UTI, was observed multiple times with an uncovered catheter bag placed on the floor underneath their wheelchair. This was noted in the dining area and hallway over a span of three days. The facility's policy, dated 9/2014, clearly states that catheter bags should be kept off the floor to prevent catheter-associated urinary tract infections. Similarly, R368, who has intact cognition and is on enhanced barrier precautions, was observed with an uncovered catheter bag in contact with the floor under their bed. Despite the presence of a sign indicating enhanced barrier precautions, the catheter bag was not managed according to the facility's policy. The Director of Nursing confirmed that catheter bags should be covered and off the floor, indicating a lapse in adherence to the established procedures designed to prevent infections.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of drugs for three residents. Resident 7 did not receive eight doses of scheduled medication due to unavailability. This resident, who had intact cognition and was responsible for their healthcare decisions, expressed frustration over the recurring issue of medication shortages, particularly with their pain medication, OxyContin. The facility staff attempted to address the issue by contacting the resident's provider and the facility's Medical Director, but the problem persisted, leading to missed doses of several medications. Resident 114, who had severe cognitive impairment, did not receive a scheduled dose of Depakote ER because the medication was not crushable, and the alternative form, Depakote sprinkles, was not available. The LPN preparing the medication confirmed the unavailability and the inability to administer the prescribed medication at the scheduled time. This issue was acknowledged by the nursing staff, who had requested the alternative form from the pharmacy but had not received it in time. Resident 15, with moderate cognitive impairment, was administered an expired medication by an LPN. The LPN dispensed an expired iron tablet and disposed of it improperly in a garbage bin on the medication cart. The facility's policy required medications to be disposed of in a Drug Buster, but the LPN confirmed that non-narcotic medications were typically disposed of in the garbage bin. This improper disposal practice was confirmed by the RNM and DON, who acknowledged that medications should not be disposed of in the garbage bin on the medication cart.
Delay in Laboratory Services Leads to Treatment Delay
Penalty
Summary
The facility failed to ensure prompt laboratory services for a resident, identified as R25, which resulted in a delay in starting necessary antibiotic treatment. R25, who had intact cognition and was responsible for their healthcare decisions, had an order for a wound culture to be completed on January 2, 2025. The culture was collected on the same day but was not sent to the laboratory until January 4, 2025. The laboratory subsequently informed the facility on January 5, 2025, that the culture could not be used because it was not processed in a timely manner. Consequently, a second culture had to be obtained on January 5, 2025, and sent to the lab. The delay in processing the initial culture led to a postponement in diagnosing the infection and starting the appropriate antibiotic therapy. The culture results, which were finally obtained on January 8, 2025, indicated the presence of Escherichia coli and staph, prompting the provider to order antibiotic treatment. Interviews with the Registered Nurse Managers and the Director of Nursing confirmed that the initial culture was not picked up timely, which directly contributed to the delay in treatment for R25.
Failure to Provide Prescribed Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R1, who was admitted with a prescription for Vyvanse. R1 did not receive the prescribed medication from 11/9/24 through 11/11/24 due to a series of communication and procedural failures. Upon admission, the hospital provided two scripts for R1, but not for Vyvanse. The prescriber attempted to send a Vyvanse script to the pharmacy on 11/8/24, but it did not go through, and the facility was not informed. Over the weekend, R1's family brought Vyvanse from home, but it was not in the original container, so staff could not administer it. Consequently, R1 did not receive the medication, leading to increased anxiety and upset. Interviews with staff revealed that there was a lack of follow-up to ensure the medication was obtained from the pharmacy. RN-E, who assisted with R1's admission, confirmed that the Vyvanse script was expected but not received, and RN-F noted that the pharmacy did not send the medication over the weekend. The Nursing Home Administrator acknowledged the communication breakdown between the provider and the pharmacy but could not provide documentation of any staff education related to the incident. R1, who was responsible for their own healthcare decisions, was discharged against medical advice shortly after the incident.
Failure to Provide Prescribed Double Entree for Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who had an order for double entree portions at all meals to aid in wound healing. The resident, who had diagnoses including dementia, a laceration on the left great toe, and a stage 3 pressure ulcer, was observed not receiving the prescribed double entree during a lunch meal. The resident's medical record clearly indicated the need for double entrees at all meals, which was not adhered to during the observed meal. The deficiency was identified during an observation where a dietary aide served the resident a single entree despite the meal ticket indicating a double portion was required. The dietary aide was unsure why the resident did not receive the double entree. The Food Safety Manager confirmed the oversight and acknowledged the need for training, indicating that the resident should have received the therapeutic diet as ordered.
Failure to Prevent Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident, identified as R1, who was subjected to inappropriate sexual behavior by another resident, R2. During the night shift, an LPN observed R2 attempting to kiss another resident, R6, and documented the incident. However, no interventions were implemented to prevent further incidents. Subsequently, an RN observed R2 engaging in inappropriate behavior with R1, who was unable to consent due to severe cognitive impairment. This incident was not immediately addressed with appropriate supervision or interventions. R2 had a history of sexually inappropriate behavior, including making inappropriate comments and touching staff, which was documented in nursing notes prior to the incident with R1. Despite this history, R2 was not placed under increased supervision until after the incident with R1. The facility's policy on abuse prevention was not effectively implemented, as there was a lack of timely intervention and supervision for R2, who had severe cognitive impairment and a history of inappropriate behavior. The facility's failure to supervise R2 and protect other residents from potential abuse led to a finding of immediate jeopardy. The deficiency was identified when the surveyor reviewed the facility's records and interviewed staff, revealing that the facility did not take adequate measures to prevent further incidents after R2's initial inappropriate behavior. The facility's inaction in addressing R2's behavior and ensuring the safety of other residents contributed to the deficiency.
Removal Plan
- Placed R2 on 1:1 supervision and moved R2 to a different unit.
- Initiated facility-wide education on abuse and 1:1 supervision.
- Completed psychosocial interviews with R1, R2, and R6.
- Updated R1, R2, and R6's care plans.
- Notified R1, R2, and R6's physicians, representatives, and local law enforcement.
- Interviewed residents and staff and initiated monitoring for changes in behavior of non-interviewable residents.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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