Wi Veterans Home Moses Hall
Inspection history, citations, penalties and survey trends for this long-term care facility in King, Wisconsin.
- Location
- 210 Cumberlidge Ave, King, Wisconsin 54946
- CMS Provider Number
- 525718
- Inspections on file
- 23
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Wi Veterans Home Moses Hall during CMS and state inspections, most recent first.
A resident with anoxic brain damage, dysphagia, dementia, and impulsive eating behaviors was on a regular texture diet with thickened liquids, with the POA accepting risks for quality-of-life food choices. While being assisted with a meal that included a peanut butter sandwich, the resident grabbed half the sandwich, placed it in the mouth, and began choking when the CNA briefly stepped away to get a towel. On return, the CNA noted breathing difficulty, activated emergency systems, and nurses responded and performed the Heimlich maneuver. The resident became unresponsive, was moved to the floor, and staff continued the Heimlich until the resident became pulseless and apneic. Staff did not call 911 or initiate CPR, citing the resident’s DNR status, even though facility policy required calling 911 for complete choking while the person was still breathing; the medical examiner later confirmed death due to choking.
Two residents with dysphagia and cognitive/vision impairments were not provided their prescribed adaptive drinking and dining equipment during meals, contrary to facility policy and care plans. One resident with MS, early-onset Alzheimer’s disease, and moderate cognitive impairment was served hot, thickened coffee in an uncovered cup and, while attempting to pour it into a personal thermal mug without supervision, spilled it into the lap, causing bilateral thigh burns with blistering. Another legally blind resident with vascular dementia and dysphagia was served lunch with an open coffee cup and a blue plate instead of the ordered lidded cup and white divided plate, and was observed searching for utensils until staff intervened. Staff interviews showed reliance on care plans/Kardex at the nurses’ station to identify adaptive equipment, incomplete dysphagia cards, and delayed delivery of the adaptive equipment bin, while a coffee sample from the same cart was measured at a temperature capable of causing severe burns within seconds.
A resident with dementia, hallucinations, mood disturbance, and moderately impaired cognition made two separate allegations of physical abuse by staff. The facility’s abuse policy required a thorough investigation, including identifying possible witnesses and having RNs follow up with all staff on duty during the time of the alleged incidents and the two prior shifts. However, for each allegation, only one or two staff members were interviewed, despite other staff being on the unit or assigned to the resident. Leadership (DON, ADON, NHA) acknowledged that additional staff who were working at the time should have been interviewed but were not, resulting in incomplete investigations of the abuse allegations.
Two residents experienced significant medication errors when duplicate medication orders were not properly discontinued, resulting in one resident receiving double doses of baclofen and requiring hospitalization, and another receiving double doses of long-acting insulin, leading to episodes of hypoglycemia. Facility staff did not follow established procedures for order transcription, review, or error investigation, contributing to these incidents.
Surveyors found that food items for resident consumption were not properly labeled or were past discard dates, and kitchen equipment was not maintained in a clean or covered condition. The Dietary Manager confirmed these lapses, which did not meet professional standards for food storage, preparation, and equipment sanitation.
A resident reported $150 missing from their room, but the facility failed to thoroughly investigate the allegation. The resident, who was not cognitively impaired, had withdrawn the money for a shopping trip and refused secure storage. The investigation did not include interviews with all staff who had access to the resident's room, contrary to facility policy.
A resident with Alzheimer's dementia and a history of falls did not have a call light within reach while seated in a recliner. The call light was observed wrapped around a trapezius bar above the bed, making it inaccessible. An LPN and the DON confirmed the call light was not within reach, which was not in accordance with facility policy.
A resident with a suprapubic urinary catheter did not receive documented routine site care to prevent UTIs. Staff and the DON were unable to provide evidence or a clear policy for suprapubic catheter care, and the resident's medical record lacked documentation of such care, despite the resident's history of frequent UTIs.
A resident with multiple chronic conditions was found receiving oxygen therapy without a current physician order or care plan, and the oxygen equipment in use was not properly labeled or maintained according to facility policy. Staff confirmed the absence of required documentation and oversight for the resident's oxygen therapy.
Two residents on enhanced barrier precautions due to indwelling medical devices did not receive proper infection control measures when an LPN failed to wear a gown during high-contact care activities, such as catheter care and G-tube medication administration, despite facility policy requiring gown use for these procedures.
Failure to Follow Choking Policy and Call 911 During Complete Airway Obstruction
Penalty
Summary
The deficiency involves the facility’s failure to follow its choking incident policy for a member who experienced a complete choking episode while still breathing. The member had multiple diagnoses including anoxic brain damage, dysphagia, dementia with mood disturbance and anxiety, impulse disorder, unspecified psychosis, personality change due to a known physiological condition, and aphasia. The member’s MDS showed intact cognition, and the member had an activated POA for healthcare who was actively involved in care. The member’s diet order included a general diet with regular texture and honey-thick liquids, and the care plan documented dysphagia therapy, the need for assistance with eating meals, and that the POA accepted the risks of the member consuming items outside the ordered diet for pleasure and quality of life. On the day of the incident, a CNA was assisting the member with supper in the dining room. The meal included beverages, diced pears, and a peanut butter sandwich cut in half. The member refused a drink, grabbed half of the sandwich, and shoved it into the mouth, then requested a towel for the lap. The CNA stepped away a short distance to retrieve a towel from a nearby linen cart. When the CNA returned, the member was noted to be having trouble breathing, and the CNA activated the emergency systems and requested another CNA to get the nurse. The member’s history included impulsive behavior, lack of judgment, disorganized eating and swallowing, and a tendency to become agitated if food was modified or sandwiches were cut into smaller pieces, and the speech pathologist confirmed the member required one staff for supervision during meals and that the care plan did not include an intervention to keep meal trays out of the member’s reach. In response to the choking episode, the RN supervisor and an RN arrived and initiated the Heimlich maneuver. The member became unresponsive but still had a pulse, and staff moved the member from the wheelchair to the floor and continued the Heimlich maneuver until the member became pulseless and non-breathing. Staff did not call 911 or initiate CPR because the member’s code status was DNR, despite the facility’s choking incident policy directing staff to call 911 when a person shows signs of complete choking and is still breathing. The medical examiner later confirmed the cause of death as choking, and the nursing home administrator verified that staff did not follow the facility’s choking policy and procedure and did not call 911 when the member showed signs of complete choking.
Failure to Provide Prescribed Adaptive Drinking Equipment Resulting in Coffee Burns
Penalty
Summary
The deficiency involves the facility’s failure to ensure adaptive eating and drinking equipment was used during meals to prevent burns for two members, M2 and M6, as required by facility policy and their care plans. The facility’s Adaptive Equipment policy and Member Meals and Snacks policy required that adaptive equipment be available and provided at needed meal times, based on care plans. M2’s care plan included an intervention for an insulated coffee mug with lid, and M2 had orders for a general ground diet with nectar thick liquids. Despite this, on the evening of 3/1/26, M2 was served supper with hot, thickened coffee in an uncovered cup placed within reach. The CNA who delivered the tray removed the lid from the coffee cup to allow it to cool and then left to retrieve M2’s adaptive equipment, leaving M2 alone with the uncovered hot coffee. While the CNA was away, M2, who had multiple diagnoses including MS, generalized muscle weakness, early onset Alzheimer’s disease, dysphagia (oropharyngeal phase), and moderate cognitive impairment (BIMS score 9/15), attempted to pour the hot, thickened coffee from the uncovered cup into a personal thermal mug. M2 missed the mug, and the coffee spilled into M2’s lap, resulting in burns to both thighs. Initial assessment noted a reddened area on the right upper thigh, and a wound assessment the following day documented an intact blister on the left thigh and a partially intact blister with granulation tissue and scant exudate on the right thigh. The incident was documented in a facility-reported incident, and the burns were directly linked to the spill of hot coffee that had been provided without the prescribed adaptive covered mug. For M6, the facility also failed to provide prescribed adaptive equipment during a meal. M6 had diagnoses including GERD, legal blindness, vascular dementia, dysphagia oral phase, and esophageal obstruction, with moderate cognitive impairment (BIMS 12/15). M6’s care plan specified adaptive equipment including a coffee cup with lid and a white deep dish divided plate. During a lunch observation, M6 was served a meal with an open cup of coffee and a blue plate instead of the ordered white divided plate. M6, who is legally blind, was observed feeling around for silverware until staff assisted by explaining the food and helping locate utensils. Staff interviews revealed that adaptive equipment information was only available in the care plan/Kardex at the nurses’ station, that M6’s adaptive equipment bin arrived late after M6 had already been served, and that M6’s dysphagia card did not list needed adaptive equipment. A coffee sample from the same cart used for M6’s meal measured 146.6°F, and surveyors noted that third-degree burns can occur at similar temperatures within seconds.
Failure to Thoroughly Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of staff physical abuse made by one member, M3, in accordance with its own Prohibition and Prevention of Member Abuse, Neglect, and Exploitation policy. The policy, revised July 2024, requires the Nursing Supervisor or Administrator to immediately initiate reporting and conduct a thorough investigation, including obtaining a list of possible witnesses, placing staff statement forms on the 24‑hour board, and ensuring RNs follow up with all staff who were on duty and may have provided care during the time of the alleged incident and the two previous shifts. M3, who had dementia with Lewy body disorder, dementia with moderate agitation, visual hallucinations, mood disturbance, a BIMS score of 9/15 indicating moderately impaired cognition, and an activated POAHC, made abuse allegations on 12/15/25 and 1/3/26. Surveyor review of the investigations and staff schedules for the 12/14/25 night shift and 1/3/26 showed that staff who were working at the time of the allegations were not interviewed. For the 12/15/25 incident, only RN‑G and CNA‑F were interviewed, despite other staff being assigned to the unit; the ADON stated that other staff were assisting on another unit when the incident occurred but acknowledged they should have been interviewed. For the 1/3/26 incident, the investigation file contained only an email statement from RN‑H, with no other staff statements, and both the NHA and DON confirmed that other staff working at the time should have been interviewed but were not. These omissions demonstrate that the facility did not complete the required comprehensive staff interviews for either abuse allegation.
Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication order transcription and administration processes. One resident with Parkinson's disease and chronic kidney disease received five extra doses of baclofen over two days as a result of a duplicate order not being discontinued when a new order was entered. The resident exhibited symptoms of overdose, including extreme drowsiness, leg tremors, confusion, and was ultimately transported to the hospital for evaluation and treatment. The duplicate orders were present in the medication administration record, and the error was not identified until after multiple double doses had been administered. Another resident with type 2 diabetes mellitus was affected by a medication error involving long-acting insulin. The resident was supposed to transition from one insulin product to another when the initial supply was exhausted, but both insulin orders remained active in the system. As a result, the resident received double doses of long-acting insulin on two occasions, which led to episodes of asymptomatic hypoglycemia detected by a continuous glucose monitoring device. The error was not identified or investigated by facility staff at the time. In both cases, the facility's policies required careful transcription, review, and discontinuation of old orders when new ones were entered, as well as prompt reporting and investigation of medication errors. However, these procedures were not followed, resulting in significant medication errors for both residents. The facility did not conduct timely or documented audits to identify or prevent similar errors, and there was a lack of immediate investigation or staff education following the incidents.
Deficient Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as observed during a kitchen inspection. Surveyors found multiple food items intended for resident consumption that were not properly labeled or were past their discard dates, including a tater tot casserole with no use-by date, a gluten-free hot dog bun with no year or use-by date, and an open box of turkey breasts with no use-by date. The Dietary Manager confirmed that these items were past expiration and should have been discarded. These practices were not in accordance with the 2022 FDA Food Code requirements for date marking and safe storage of ready-to-eat, time/temperature control for safety foods. Additionally, the facility did not maintain kitchen equipment in a clean condition or store it properly. Surveyors observed a coffee dispensing machine with dried coffee debris inside, and the cleaning log indicated it had not been cleaned for over two months, despite a policy of weekly cleaning. Three standing mixers, a vertical cutter mixer (VCM), and several VCM disc blades were found uncovered when not in use. The Dietary Manager acknowledged that these items were not covered, which is inconsistent with professional standards for storing clean equipment and utensils to prevent contamination.
Incomplete Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident, identified as R73, who reported $150 missing from their room. The incident occurred after R73 withdrew money for a shopping trip and refused to have it securely stored. The investigation was incomplete as not all staff who had access to R73's room during the relevant timeframes were interviewed. The facility's policy requires a thorough investigation, including interviewing all potential witnesses and staff who may have been involved. R73, who was not cognitively impaired as indicated by a BIMS score of 15 out of 15, reported the missing money on the day of the shopping trip. The investigation documentation included statements from nine staff members, but four staff who had access to R73's room during the specified shifts were not interviewed. Both the Commandant and the Director of Nursing acknowledged that the investigation did not meet the facility's policy requirements, as not all relevant staff were interviewed.
Call Light Not Within Reach for Resident with Fall Risk
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia, chronic obstructive pulmonary disease, and adult failure to thrive did not have a call light within reach while seated in a recliner. The resident's Minimum Data Set assessment indicated moderately impaired cognition, and the care plan identified a risk for falls with an intervention to remind the resident to call for assistance. On observation, the call light was found wrapped around a trapezius bar above the bed, making it inaccessible to the resident. Both an LPN and the Director of Nursing confirmed that the call light was not within reach, contrary to the facility's policy requiring call lights to be accessible to residents.
Failure to Provide and Document Suprapubic Catheter Site Care
Penalty
Summary
Staff failed to provide appropriate suprapubic catheter site care for a resident with a history of Parkinson's disease, chronic kidney disease, and an atonic bladder requiring a suprapubic urinary catheter. The resident's medical record did not contain any orders or documentation indicating that routine suprapubic catheter site care was provided to prevent urinary tract infections (UTIs), although the catheter was changed monthly as ordered by the physician. The resident reported experiencing frequent UTIs in the past, which had improved more recently. During the survey, staff interviews revealed uncertainty regarding the facility's policy on suprapubic catheter care, and the Director of Nursing (DON) was unable to provide documentation that the required site care was completed. The facility's available policy only referenced cleansing the site during catheter insertion or removal and routine perineal care for Foley catheters, not for suprapubic catheters. Observations and interviews confirmed that there was no evidence of regular suprapubic catheter site care being performed or documented for the resident.
Oxygen Therapy Provided Without Physician Order or Proper Documentation
Penalty
Summary
A resident with diagnoses including chronic diastolic (congestive) heart failure, obstructive sleep apnea, and type 2 diabetes mellitus with diabetic chronic kidney disease was observed receiving oxygen therapy at 6 liters per minute via nasal cannula, connected to an oxygen concentrator. The resident's medical record did not contain a physician order or care plan for oxygen therapy, and the oxygen tubing and humidifier canister in use were not dated as required by facility policy. Staff interviews confirmed that the resident had been using oxygen without a current physician order specifying the dose, route, or pulse oximetry parameters, and that the required documentation and labeling procedures were not followed. The facility's policy mandates a provider's order for extended oxygen use, including specific instructions for administration and equipment maintenance. Despite this, the resident was receiving oxygen therapy without the necessary order or care plan, and the equipment in use was not properly labeled or maintained according to policy. Both the respiratory therapist and the director of nursing acknowledged the absence of required orders and care planning for the resident's oxygen therapy at the time of the survey.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as required for two residents who were on enhanced barrier precautions (EBP) due to the presence of indwelling medical devices. One resident, who had an indwelling urinary catheter and was not cognitively impaired, was observed during catheter care when an LPN emptied the Foley catheter bag without wearing a gown, contrary to the facility's EBP policy. The LPN confirmed awareness of the policy and acknowledged that a gown should have been worn during this high-contact care activity. Similarly, another resident with a gastrostomy tube (G-tube) and no cognitive impairment was observed receiving medication via the G-tube from the same LPN, who again did not wear a gown as required by the EBP policy. The LPN verified that a gown should have been worn during this procedure. The Director of Nursing also confirmed that both residents were on EBP and that gown use was required for these high-contact care activities, as outlined in the facility's policy.
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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