Waunakee Valley Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Waunakee, Wisconsin.
- Location
- 801 Klein Dr, Waunakee, Wisconsin 53597
- CMS Provider Number
- 525098
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Waunakee Valley Senior Living during CMS and state inspections, most recent first.
A resident with CHF, cardiomyopathy, atrial fibrillation, and respiratory failure was not monitored with daily weights or timely assessments despite hospital discharge instructions and weight-gain parameters. The resident had significant weight gains, bilateral edema, weeping ankles, SOB, and diminished lung sounds, yet staff did not consistently notify the MD or document ongoing CHF monitoring before the resident required hospitalization for acute exacerbation of chronic heart failure.
Failure to Provide and Monitor Ordered BIPAP Therapy: A resident with OSA and respiratory failure had an order for BIPAP, but the settings were left blank in the admission order, staff did not verify proper settings, and repeated refusals were not escalated to the physician. Facility records showed BIPAP use was documented despite remote DME data showing little to no actual use, and the resident later required ER transfer for worsening hypoxia and hypercarbia, with the ER noting chronic BIPAP nonuse as the likely cause of the exacerbation.
Inaccurate Infection Control Rate Tracking: The facility did not maintain an accurate IPCP surveillance system. The DON stated monthly infection control rates were calculated only for residents with facility-acquired infections and were not tracked by infection type. The IC Rates form did not match the respiratory surveillance line list or ATB surveillance log, and an updated form later showed more facility-acquired infections than the original record.
Failure to Assess Self-Administration of Medications: A resident with CKD, malnutrition, and heart disease was observed with 3 cups of meds left at the bedside to take independently. Although the resident had a BIMS of 15, the facility had no self-administration assessment or specific MD order, and an LPN stated the resident was independent with meds while the NHA confirmed no assessment could be found and meds should not be left at bedside without one.
Failure to document and verify safe smoking for a resident: A cognitively intact resident with cancer, depression, and bipolar disorder was known by staff to be smoking and going off premises twice daily, yet the facility could not produce a smoking assessment. Surveyor observation found cigarettes and a lighter stored in the resident’s dresser, while the NHA and MDS Coordinator acknowledged there was no formal smoking assessment documentation in the system.
A resident with a history of depression did not receive necessary behavioral health services after her husband's death. Despite clear signs of depression, including poor appetite and expressions of wanting to die, the facility failed to implement a person-centered care plan or provide psychiatric evaluation and counseling. Staff observed the resident's decline but did not take adequate action to address her mental health needs.
A resident in an LTC facility experienced significant medication errors when abiraterone, a prostate cancer medication, was administered late on two occasions. Despite clear instructions for the medication to be taken on an empty stomach and within a specific time frame, staff interviews revealed a failure to adhere to these guidelines. The resident was cognitively intact, and the errors were not reported to administrative staff as required.
A resident with multiple mental health diagnoses, including bipolar disorder and PTSD, was admitted to the facility without a completed PASRR Level II, despite staying beyond the 30-day exemption period. The Director of Social Services acknowledged the requirement for a Level II PASRR but was unsure if it was completed, indicating a lapse in the facility's adherence to the PASRR process.
The facility failed to ensure proper nursing assessment protocols, as LPNs conducted complete assessments for two residents without RN co-signature or notification, contrary to professional standards. Interviews revealed confusion among staff regarding assessment responsibilities, highlighting a systemic issue in adhering to nursing practice standards.
A medication cart was left unlocked and unattended in a hallway, contrary to the facility's policy requiring carts to be locked when not attended by authorized personnel. An LPN admitted to leaving the cart unlocked, and the DON confirmed that the expectation was for carts to be locked when unattended.
A resident with dementia and a history of wandering eloped from a facility without triggering the Wanderguard alarm system. The facility was unaware of the resident's absence until contacted by law enforcement. Staff interviews revealed that the alarm system did not activate, and the resident's care plan indicated a known risk for elopement. The failure to provide adequate supervision and ensure the functionality of safety devices led to a finding of immediate jeopardy.
The facility did not ensure CNAs received annual performance reviews as required, affecting five CNAs who had not been evaluated within the past 12 months. The facility lacked a policy for conducting these evaluations, and instead, implemented quarterly wage increases and PIPs when necessary. The Assistant Divisional President acknowledged the absence of yearly evaluations, contrary to the State Operations Manual requirements.
The facility did not ensure food was served at a palatable temperature, as a test tray showed food temperatures outside the acceptable range. The meat and noodles were at 123.8°F, corn at 125.8°F, and milk at 41.7°F, contrary to the facility's guidelines. The Director of Food Services acknowledged the issue.
A resident did not receive scheduled medications, including Acetaminophen, Aspirin, and Lacosamide, on ten occasions due to late administration outside the designated time range. The LPN admitted to administering the medications late without notifying the provider to adjust the schedule, and the DON confirmed the documentation errors.
Two residents in a LTC facility developed pressure ulcers due to inadequate care. One resident returned from hospitalization with a Foley catheter and developed a full-thickness wound due to improper interventions and lack of assessments. Another resident developed a stage 2 pressure ulcer on the coccyx, with the facility failing to notify the physician of worsening conditions and not ensuring proper hand hygiene during wound care. The facility's policies on wound and catheter care were not followed, leading to immediate jeopardy.
The facility failed to report alleged violations involving abuse, neglect, and misappropriation within the required timeframe for four residents. Incidents included a CNA being rude, a resident with a black eye, neglect in personal hygiene assistance, and theft of personal items. The Nursing Home Administrator admitted these should have been reported to the State Agency, indicating a lapse in following regulatory reporting procedures.
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation involving four residents. A resident reported a CNA being rude, another had an unexplained black eye, a third was denied assistance with personal hygiene, and a fourth reported missing personal items. The facility did not identify these as potential abuse cases, failed to interview involved parties, and lacked complete documentation of investigations.
A resident with multiple diagnoses, including Metabolic Encephalopathy and congestive heart failure, reported not feeling well and had a gray emesis. The nurse only took vital signs and did not perform a thorough assessment or notify the physician. The resident was later found deceased with black liquid emesis present. Staff interviews revealed that a more comprehensive assessment should have been conducted, and the facility lacked a specific policy on nurse assessments.
Failure to Monitor CHF Resident Weights and Symptoms
Penalty
Summary
The facility did not ensure that a resident with CHF received necessary care and services in accordance with professional standards of practice. The resident was admitted with diagnoses including CHF, hypertension, obstructive sleep apnea, and respiratory failure, and the hospital discharge paperwork noted cardiomyopathy, atrial fibrillation, and heart failure with reduced ejection fraction. The discharge summary also documented a weight of 248 lbs and instructed staff to notify the physician if the resident’s weight increased or decreased by 3 lbs in one day or 3 lbs in one week. After admission, the resident was not weighed for the first 12 days at the facility. When a weight was finally obtained, it showed 260 lbs, which was documented by the dietitian as a +12 pound significant weight gain over 2 weeks. The record did not show physician notification at that time. The resident was later weighed at 261 lbs, reflecting a 13-pound gain from the earlier hospital weight, and again there was no evidence of physician notification. Additional weights were not documented for several days afterward, and there was no evidence that nursing staff monitored or assessed the resident for signs or symptoms of CHF exacerbation or edema during that period. The resident later had documented bilateral lower extremity edema, and subsequent notes described increasing edema, declining function, and verbal responses. The physician was updated and the resident was sent to the ER for evaluation and treatment of cardiac declines exacerbated by his muscular disorder. The resident was then admitted to the hospital with acute exacerbation of chronic heart failure with reduced ejection fraction, and hospital notes stated that the etiology was not entirely clear though diet and fluid indiscretion were possible because monitoring prior to admission was unclear. After discharge, the resident was again not weighed daily despite the hospital’s instructions to weigh before breakfast and not gain more than 3 lbs in one day or 5 lbs in a week. When the wife later requested the daily weights, staff found no orders for daily weights at that time, noted 2-3+ pitting edema with weeping around the ankles, and documented shortness of breath with repositioning and diminished lung sounds.
Failure to Provide and Monitor Ordered BIPAP Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident with congestive heart failure, hypertension, obstructive sleep apnea, and respiratory failure. The resident was cognitively intact with a BIMS score of 15 and was admitted with hospital discharge instructions stating to continue wearing home CPAP/BIPAP during sleepiness unless otherwise instructed. The physician’s admission orders included an auto BIPAP order, but the settings were left blank, and the record showed the resident was also ordered oxygen via nasal cannula at bedtime. Facility documentation showed the resident was recorded as wearing the BIPAP on most days early in the stay, but the same record also showed refusals on multiple dates. The facility tracked oxygen saturation daily for a limited period and then did not document it again until later in the stay. The resident’s treatment record directed staff to observe for signs of respiratory distress and notify the physician of new or worsening symptoms. On 10/13/25, the facility documented that the doctor was updated on recent declines in function, verbal responses, and increasing edema, and the resident was sent to the ER for evaluation and treatment of cardiac declines. The ER record stated the resident arrived with worsening hypoxia and ongoing hypercarbia and noted that the resident was on chronic BIPAP but did not appear to have been using it, which was identified as the most likely cause of the exacerbation. The resident later told the surveyor that the BIPAP was uncomfortable and that he had been using nasal cannula instead at night. Sleep clinic and DME records showed the resident had previously used the BIPAP consistently, then had markedly reduced use during the period before hospitalization. Surveyor interviews with nursing staff and the DON indicated staff expected BIPAP settings to be verified and physicians to be notified for repeated refusals, but the facility did not ensure the BIPAP settings were correct, did not ensure the device was being worn according to remote DME data, and did not contact the physician after repeated refusals.
Inaccurate infection control rate tracking and no infection-type breakdown
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The facility policy for the Infection Prevention and Control Program stated that the campus has a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, including surveillance activities to identify, investigate, control, and prevent the spread of infection and reporting for the IPCP, with infections tracked per hall/unit and type of infection. During record review and interview, the facility's Infection Control Rates 2025/2026 form showed monthly totals for January, February, and March 2026, but the rates were not documented accurately and were not broken down by infection type. On 4/9/26, the DON stated the facility calculated monthly infection control rates only by including residents who had a facility-acquired infection and did not track residents admitted with an infection. The DON also stated the facility did not track infection control rates based on type of infection and could not determine rates for UTIs, wounds, respiratory infections, and other types from the form. The facility's LTC Respiratory Surveillance Line list for February 2026 included 3 residents positive for facility-acquired COVID, and the Infection Tracking - Antibiotic Surveillance Log for February 2026 included 4 residents with a facility-acquired infection, while the IC Rates form listed only 4 total residents for that month. Later that day, the facility provided an updated Infection Control Rate form showing 7 residents with a facility-acquired infection, indicating the original form was not accurate.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility did not ensure that all residents were clinically appropriate to self-administer medications for 1 of 1 sampled residents reviewed for self-administration. R10 was observed with 3 cups of medications left on the bedside table to take independently. R10 was admitted with diagnoses including chronic kidney disease, malnutrition, and heart disease, and the most recent MDS dated 3/27/26 showed a BIMS score of 15 out of 15, indicating cognitive intactness. The facility policy titled Guidelines for Self-Administration of Medications states that residents requesting to self-medicate or who have self-medication as part of their plan of care shall be assessed using the facility's self-administration assessment in the EHR, and the results are to be presented to the physician for evaluation and order. During interview, R10 stated staff leave medications on the table when they are sleeping so they can take them with breakfast. An LPN stated that R10 takes medications themselves and is independent with medications, but also stated there was no assessment for self-administration and no specific physician order for R10 to self-administer medications. The requested assessment was not provided, and the NHA also stated no assessment could be found and that R10's medications should not be left at bedside without an assessment.
Failure to Document and Verify Safe Smoking for a Resident
Penalty
Summary
The facility did not ensure adequate supervision and safety to prevent accidents for one resident who was smoking. The resident was admitted with diagnoses including breast cancer, bone cancer, major depressive disorder, and bipolar disorder, and the most recent MDS dated 4/2/26 showed a BIMS score of 15 out of 15, indicating cognitive intactness. Although the resident’s care plan dated 7/9/25 stated that the resident currently used tobacco and included interventions related to smoking, the resident’s smoking status was not reflected in the MDS until 4/2/26, even though staff were aware the resident was smoking in July 2025. Surveyor interviews and observation showed that the resident reported smoking twice a day, going off premises to smoke, and keeping cigarettes and a lighter in the top drawer of the dresser. The surveyor observed a pack of cigarettes and a lighter in that drawer. When asked for a smoking assessment, the facility could not provide one. The NHA stated the facility was a non-smoking facility and did not have an assessment, later stating staff were aware the resident was going outside to smoke and that an MDS Coordinator had completed an assessment in July, but no documentation existed in the computer system and no notes were taken. The MDS Coordinator stated a care plan was added when staff learned the resident was smoking, but also stated there was no smoking assessment in the system and no documentation of the assessment.
Failure to Provide Behavioral Health Services for Resident with Depression
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident, identified as R11, who was admitted with a history of depression. Despite R11's significant life event of losing her husband, the facility did not offer appropriate psychological support or services related to her depression diagnosis. The resident's care plan included interventions such as encouraging social interaction and monitoring for signs of depression, but these were not effectively implemented or personalized to address her ongoing decline. R11's medical records indicated multiple instances of depression, with symptoms such as poor appetite, increased sleep, and expressions of wanting to die. Despite these clear signs of depression, the facility did not prescribe any medication specifically for depression, as the trazodone prescribed was intended for insomnia. The facility's staff, including CNAs and LPNs, observed R11's decline and reported it, but no significant actions were taken to address her mental health needs. Interviews with facility staff revealed a lack of follow-through on care plan interventions, such as referrals for psychiatric evaluation and counseling services. The Director of Social Services acknowledged informal contacts but did not pursue recommended grief services. The Nursing Home Administrator and Director of Nursing both recognized the deficiency in care planning and implementation, noting that R11's care plan should have been updated to reflect her ongoing depression and decline.
Significant Medication Error Due to Late Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of abiraterone, a medication used to treat prostate cancer. The resident, who was cognitively intact with a BIMS score of 14 out of 15, had specific instructions for the medication to be taken on an empty stomach with a full glass of water, and not to eat for at least two hours before and one hour after taking it. However, the medication was administered late on two occasions, which constituted significant medication errors. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that there was an understanding that medications should be administered according to physician orders. Despite this, the medication was not given within the specified time frame, and the late administration was not reported to administrative staff as expected. The facility's policy on medication administration times was not adhered to, leading to the deficiency noted by the surveyors.
Failure to Complete PASRR Level II for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to adhere to the Preadmission Screening and Resident Review (PASRR) process for a resident, identified as R48, who was admitted in April 2024. R48, who has diagnoses including bipolar disorder, major depressive disorder, PTSD, adjustment disorder, and other anxiety disorders, did not have a PASRR Level II completed as required. The facility follows the Wisconsin PASRR Quick Reference Guide, which mandates a Level I PASRR screen for all residents prior to admission and a Level II screen if the resident stays beyond a short-term exemption period. R48's PASRR Level I was completed with a 30-day exemption, but no Level II was conducted despite the extended stay. During an interview, the Director of Social Services (DSS C) acknowledged that a Level II PASRR should be completed if a resident stays longer than the anticipated 30 days. DSS C expressed uncertainty about whether a Level II PASRR was completed for R48, stating that if there was no copy available, it might have been missed. This oversight indicates a lapse in the facility's adherence to the PASRR process, as there was no documented evidence of a Level II PASRR for R48, despite the resident's extended stay and mental health diagnoses.
Deficiency in Nursing Assessment Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the completion and oversight of nursing assessments. Two residents, identified as R52 and R305, were affected by this deficiency. Both residents had nursing assessments completed and signed by Licensed Practical Nurses (LPNs) without the required co-signature or notification of a Registered Nurse (RN). This practice is not in compliance with the Wisconsin Nurse Practice Act, which mandates that RNs utilize the nursing process, including assessment, planning, intervention, and evaluation, while LPNs are only permitted to assist with data collection. Resident R52, who was cognitively intact, had multiple progress notes documenting complete head-to-toe assessments conducted by LPNs over several days. These assessments were not co-signed by an RN, nor was there any record of RN notification. Similarly, Resident R305, a new admission with significant medical conditions, had progress notes indicating complete assessments by LPNs, including pain assessments, without RN co-signature or notification. Interviews with facility staff, including LPNs and the Director of Nursing (DON), revealed a lack of clarity and adherence to the proper protocol for nursing assessments. The Director of Nursing acknowledged that LPNs can perform observations but emphasized that head-to-toe assessments should be co-signed by an RN or discussed with an RN if new findings are present. Despite this expectation, the surveyor found several instances where this protocol was not followed, indicating a systemic issue in the facility's adherence to professional standards of practice for nursing assessments.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional principles. During a three-day survey, one of three medication carts was observed to be left unattended, unlocked, and out of view of staff. Specifically, on January 21, 2025, at 9:18 AM, a surveyor observed a medication cart on A wing sitting in the hallway unlocked. At 9:19 AM, the surveyor noted that an LPN exited another room and approached the cart. Upon inquiry, the LPN admitted that the medication cart was not locked when they left it, despite the facility's policy requiring medication carts to be locked when not attended by authorized personnel. The Director of Nursing (DON) confirmed that the expectation was for nurses to lock their medication carts and take their keys with them when leaving the cart unattended. The DON acknowledged that the LPN's cart should have been locked when they left to enter another room. This incident highlights a failure to adhere to the facility's medication storage policy, which mandates that medication carts be locked when not attended by authorized personnel.
Resident Elopement Due to Wanderguard System Failure
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified as at risk for wandering and elopement. The resident, who had a history of dementia, osteoarthritis, and other conditions, was equipped with a Wanderguard device attached to her walker. Despite this precaution, the resident managed to elope from the facility without triggering the alarm system. The facility was unaware of the resident's absence until contacted by local law enforcement, who found the resident four blocks away, having crossed a busy intersection. Interviews and record reviews revealed that the Wanderguard alarm system did not activate when the resident exited the building. Staff members, including the LPN on duty, reported that no alarms were heard, and the resident was last seen sitting in the hallway before her elopement. The head nurse and other staff members were unsure why the alarm system failed, and it was discovered that one of the dining room doors did not sound an alarm when opened. The facility's policy required staff to respond promptly to alarms and conduct headcounts, but these procedures were not effectively implemented in this instance. The resident's care plan and elopement risk assessments indicated that she was at risk for wandering and elopement, with specific interventions outlined to prevent such incidents. However, the failure of the Wanderguard system and the lack of immediate staff response to the resident's exit resulted in a serious oversight. The facility's inability to provide adequate supervision and ensure the functionality of safety devices led to a finding of immediate jeopardy, highlighting a significant deficiency in the facility's safety protocols.
Removal Plan
- Nursing Assessment completed for R4.
- Placed on 1:1 and then 15-minute checks.
- Notifications of MD and responsible party made.
- Wanderguard placed on wrist.
- Facility head count was completed all residents accounted for.
- Director of Plants Operation assessed Wanderguard system and all other campus egress doors all found functioning properly.
- Door monitor placed at the nurse station.
- Repair company was contacted to assess Wanderguard system and to install a keycode pad/mag lock for the employee entrance/exit door.
- All residents reviewed for elopement risk.
- Wandering and elopement care plans were reviewed by the DON.
- All elopement binders reviewed by DON.
- Elopement drill was conducted.
- Education initiated.
- Education including: Policy Review related to increasing exit seeking behaviors and what to do if resident found outside.
- Audit on Wanderguard function 5 times weekly.
- Audit 5 staff members what to do if resident is observed an increase in exit seeking behaviors 5 times weekly and then randomly thereafter.
- Elopement drills will be completed at least quarterly.
- DON will audit residents who are currently an elopement risk twice weekly to ensure appropriate interventions are in place.
- All audits submitted to the QAPI Committee for further review.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received a performance review at least every 12 months, as required. This deficiency was identified for five CNAs who were selected for review. CNAs T, U, S, and R were all hired on March 1, 2023, and had not received an evaluation in the past 12 months, despite being due for one on or around March 1, 2024. Similarly, CNA H, hired on August 17, 2023, also had not received an evaluation within the required timeframe. The facility lacked a Policy and Procedure for conducting CNA performance evaluations. During an interview, the Assistant Divisional President (ADVP V) acknowledged that the facility does not conduct yearly evaluations for CNAs. Instead, the facility implements quarterly wage increases and Performance Improvement Plans (PIPs) when disciplinary actions are necessary. The surveyor referred ADVP V to the State Operations Manual, which mandates that facilities complete performance reviews of every nurse aide at least once every 12 months.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that all residents received food at a palatable temperature, as evidenced by a test tray that was outside of the acceptable temperature range. According to the facility's Food Production Guidelines, hot food should be held at 135°F or above, and cold food should be held at 41°F or below. During an observation, the surveyor found that the meat and noodles on the test tray were at 123.8°F, the corn was at 125.8°F, and the milk was at 41.7°F. The meat was difficult to chew, and both the meat and noodles, as well as the corn, were cold, while the milk was warm. The Director of Food Services acknowledged that hot foods should be served hot and cold foods should be served cold, indicating an understanding of the concern regarding the temperatures of the food on the meal tray.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident, identified as R3, who did not receive Acetaminophen, Aspirin, and Lacosamide as scheduled on ten separate days in August 2024. The facility's policy requires medications to be administered according to the prescriber's written orders and the established medication administration schedule. However, R3's Medication Administration Record (MAR) indicated that these medications were administered outside the designated time range of 6:00 AM to 10:00 AM on multiple occasions. The deficiency was further highlighted during interviews with LPN C, who admitted that R3 often refused morning medications, preferring to take them after breakfast. LPN C acknowledged that the medications were administered late, not just charted late, and failed to notify the provider to adjust the medication schedule. The Director of Nursing (DON B) and the Director of Health Services (DHS D) were made aware of the incorrect documentation and confirmed that the medications were indeed given late, contrary to the facility's expectations.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. Resident R4 was admitted without a pressure injury or catheter but returned from hospitalization with a Foley catheter. The facility did not implement interventions to prevent medical device-related pressure injuries, failed to complete weekly measurements and assessments, and did not perform treatments as ordered. As a result, R4 developed a full-thickness wound extending from the tip of the penis through the meatus and down to the shaft. Despite documentation of pressure from the Foley catheter causing redness, pain, and drainage, the facility did not conduct weekly assessments or measurements of the affected area. Resident R6 was admitted without a pressure injury but developed a stage 2 pressure ulcer on the coccyx. The facility did not implement interventions to prevent the development of pressure injuries upon admission, failed to notify the physician when the wound worsened, and did not ensure proper hand hygiene during wound care. The wound management notes indicated discrepancies in documentation, with two entries for the same time and date, and treatments were not signed out as completed on the Treatment Administration Record (TAR) until several days later. The facility's policies on wound care and catheter care were not followed, leading to the development and worsening of pressure injuries in both residents. The lack of timely assessments, documentation, and communication with healthcare providers contributed to the deficiencies observed by the surveyors. The facility's failure to adhere to professional standards of practice for pressure ulcer prevention and care resulted in immediate jeopardy for the residents involved.
Removal Plan
- The facility reviewed the care plan of resident to identify and complete follow up, if indicated for concerns related to the catheter device. The resident was sent to hospital for evaluation.
- The facility identified all residents currently admitted to identify any possible similar events related to abnormal findings for residents with catheters at risk for injury including but not limited to pressure ulcers.
- Facility conducted a sweep of all residents with an indwelling foley catheter to ensure interventions are in place to prevent PI development.
- Skin assessments have been completed on all residents with an indwelling catheter.
- The facility initiated proactive education with licensed nursing staff on catheter care and pressure ulcer prevention.
- Nursing staff will be educated to ensure correct positioning to prevent tubing from being taut or causing pressure on the urethra.
- Nursing staff will be educated on monitoring of skin integrity on residents with catheters during cares, paying special attention to skin impairment and will be completed with the change in condition policy. Any findings will be reported immediately.
- The facility initiated a skills check list for licensed nursing staff for catheter care.
- The facility audited all residents with catheters with or without wounds related to catheter use to ensure orders were appropriate and treatment plans were in place for care as well as prevention of pressure ulcers.
- Proactive education on the use of stat locks for catheters.
- Documentation is to include weekly measurements and assessments if a pressure ulcer is identified. These are to be signed out in the TAR as ordered.
- The facility initiated education with licensed nurses to ensure physician orders are transcribed correctly to the MAR/TAR.
- Licensed Nursing Staff were also educated on documenting and reporting changes of condition at the time of the observation to the physician as well as the resident's responsible party and hospice.
- The facility initiated reeducation with all Licensed Nursing Staff on identifying and reporting Changes of Condition when newly identified changes in health status are identified.
- The facility initiated reeducation with all Licensed Nursing Staff on completion of a comprehensive assessment on all skin events with a noted change in size, shape, and clinical presentation at the time of discovery.
- The Licensed Nursing staff was reeducated on completing a notification to the MD, RP, and or Guardian at the time of identification.
- The Licensed Nursing Staff were reeducated on catheter care including but not limited to pressure ulcer prevention and treatment.
- The Licensed Nursing staff were reeducated on transcribing orders to the MAR/TAR as ordered.
- The facility will review orders daily in the Morning Clinical Meeting to ensure that preventative orders are in place for catheters to decrease the risk for pressure.
- The facility will review Matrix EHR (electronic health record) daily during Morning Clinical Meeting to identify Changes of Condition and ensure notifications/consultations were completed. Follow up will be completed if indicated based on the outcome of the audit.
- The facility will complete random audits 3x weekly with Licensed Nurses to gauge understanding related to completion of Changes of Condition. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits 3x weekly on catheters to ensure care is provided per clinical standards. To include proper placement of leg strap/stat lock to prevent pressure. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits 3x weekly on pressure ulcers to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will complete random audits 3x weekly on treatment records and weekly skin assessments to ensure care is provided per clinical standards. Remedial education will be provided at the time of completion of audits if indicated.
- The facility will audit residents with medical device pressure injuries 3x weekly to ensure weekly assessments are documented in the medical record including measurements.
- The results of the audits will be reported to the quality assurance and performance improvement (QAPI) committee and adjustments will be made to frequency of audits based on findings.
Failure to Report Alleged Violations in a Timely Manner
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment within the required timeframe for four of ten sampled residents. According to the State Operations Manual, such allegations must be reported immediately, but not later than 2 hours if they involve abuse or result in serious bodily injury, or not later than 24 hours if they do not involve abuse and do not result in serious bodily injury. The facility's policy, updated in 2024, aligns with these requirements, yet the facility did not adhere to them in several instances. One resident reported that a Certified Nursing Assistant (CNA) was rude and yelled at them, but this was not reported to the State Agency. Another resident was found with a black eye, an injury of unknown origin, which was also not reported. Additionally, a resident reported neglect when staff refused to assist with personal hygiene, stating that they were not obligated to do so. This incident was not reported to the State Agency either. Lastly, a resident claimed that personal items, including a white ski jacket and a pair of jeans, were stolen, but this allegation of misappropriation was not reported. The Nursing Home Administrator acknowledged during interviews with the surveyor that these allegations should have been reported to the State Agency. The facility's grievance log and progress notes documented these incidents, yet there was a failure to follow through with the required reporting procedures. This oversight indicates a significant lapse in adhering to regulatory requirements for reporting suspected abuse, neglect, or theft, as outlined in the facility's own procedural guidelines.
Failure to Investigate Alleged Violations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for four residents. Resident 1 reported that a CNA was rude and yelled at them, but this allegation was not thoroughly investigated. The facility did not identify the allegation as potential abuse, did not interview other staff or residents, and did not suspend the suspected employee pending the outcome of the investigation. Additionally, there was a lack of complete documentation of the investigation. Resident 10 was found with a black eye, an injury of unknown origin, which was not thoroughly investigated. The facility failed to identify the injury as a potential abuse case, did not interview staff, did not update the physician or the resident's representative, and did not document a complete investigation. The lack of documentation in the resident's medical record further highlights the deficiency in handling this case. Resident 11 reported that staff refused to assist them with personal hygiene, which could be considered neglect. The facility did not thoroughly investigate this allegation, as they failed to interview other staff and residents, did not suspend the suspected employee, and did not document a complete investigation. Additionally, Resident 7 reported missing personal items, alleging misappropriation, but the facility did not investigate this concern thoroughly, as the NHA was unaware of the issue and no documentation of an investigation was provided.
Failure to Assess and Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards for a resident who experienced a change in condition. The resident, who had diagnoses including Metabolic Encephalopathy, Rhabdomyolysis, and congestive heart failure, reported not feeling well and had a gray emesis. Despite these symptoms, the nurse only took vital signs and did not perform a thorough assessment. The resident was later found deceased in his room with black liquid emesis present. The facility's policy on Notification of Change in Condition requires notifying the physician of significant changes in a resident's status. However, the nurse did not inform the physician of the resident's condition, nor did she conduct a follow-up assessment throughout the day. The nurse cited being overwhelmed with responsibilities as a reason for not following up. Interviews with staff, including the Director of Nursing and Nurse Practitioner, indicated that a more comprehensive assessment should have been conducted, including checking heart and bowel sounds. The Nursing Home Administrator was unable to provide a standard of practice for assessing changes in condition, and the facility lacked a specific policy on nurse assessments. The failure to conduct a focused assessment and notify the physician of the resident's change in condition contributed to the deficiency identified by the surveyors.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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