Willowcrest Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in South Milwaukee, Wisconsin.
- Location
- 3821 S Chicago Ave, South Milwaukee, Wisconsin 53172
- CMS Provider Number
- 525413
- Inspections on file
- 20
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Willowcrest Health Services during CMS and state inspections, most recent first.
The facility submitted inaccurate PBJ staffing data to CMS, resulting in a deficiency for excessively low weekend staffing. Although staff schedules showed adequate coverage by CNAs and nurses, the reported data did not capture training/orientation hours and excluded certain staff roles on weekends, leading to a significant drop in reported direct care hours.
The facility did not maintain required documentation of weekly temperature testing and flushing logs for the vacant south unit, as mandated by its water management policy. This lapse was confirmed during a survey when leadership acknowledged that the responsible maintenance staff had not completed or recorded these activities for several months, affecting all residents in the facility.
A resident with a history of anxiety and other chronic conditions continued to receive Lorazepam despite a psychiatric NP's recommendation for gradual dose reduction and discontinuation, as there were no documented behaviors to support ongoing use. The order to discontinue the medication was not processed due to communication lapses among staff, resulting in the resident receiving unnecessary psychotropic medication.
Two residents were transferred to the hospital multiple times without receiving written notification of the reason for transfer or discharge, and without proper documentation of the bed-hold policy or the rate to reserve their beds. Required sections of the bed-hold forms were often incomplete or missing, and staff interviews confirmed inconsistent practices and lack of awareness regarding the completion and distribution of these forms. Both residents and their representatives reported not receiving the necessary documentation.
A resident with severe cognitive impairment and multiple medical conditions did not receive appropriate monitoring or intervention for bowel movements, despite a care plan requiring staff to record and report abnormalities and administer PRN bowel medications as needed. Over a nine-day period without a documented bowel movement, no interventions were provided and the physician was not notified, resulting in a diagnosis of possible small bowel ileus.
A resident with severe cognitive impairment and limited range of motion in one upper and both lower extremities did not have a care plan or interventions in place to maintain or improve ROM. Staff did not provide ROM exercises during care, and documentation lacked any mention of such interventions, despite facility policy requiring them. Interviews confirmed the absence of a restorative program and reliance on therapy referrals only if a decline in ADLs was noted.
A resident with an indwelling urinary catheter was repeatedly observed with an uncovered catheter drainage bag either on the floor or hanging on the bed, contrary to the care plan which required the bag to be covered and stored in a dignity bag holder. The DON confirmed that catheter bags should be covered for dignity, but no further information was provided regarding the observed lapses.
A resident with severe cognitive impairment and a G-tube did not have the tube flushed with water prior to medication administration, as required by facility policy. An LPN administered medications via the G-tube, flushing only between and after medications, but not before the first dose. The LPN later acknowledged the omission, which was directly observed by a surveyor.
A resident with chronic respiratory conditions was observed receiving oxygen at 4 L/min via nasal cannula, despite physician orders specifying 3 L/min. Multiple observations over several days confirmed the incorrect flow rate, and staff only adjusted the setting after being notified by a surveyor. No explanation was provided for the deviation from the prescribed oxygen therapy.
A resident with PTSD did not receive trauma-informed, culturally competent care as required. The care plan lacked details about the resident's trauma, triggers, and individualized interventions. Staff were unable to identify the resident's specific needs related to PTSD, and there was no effective collaboration with mental health professionals to guide care.
A nurse administered Ambien instead of the ordered Hydrocodone-Acetaminophen for pain to a resident with multiple medical conditions, resulting in uncontrolled pain and altered mental status. The error was not identified during the required narcotic count at shift change, and was only discovered later when another LPN reviewed the records. This incident involved failures in medication verification, administration, and controlled substance reconciliation.
A resident with hypertension was prescribed Metoprolol Tartrate with instructions to hold the medication if systolic blood pressure was below 120. Nursing staff administered the medication without consistently documenting blood pressure readings prior to each dose, as required by the physician's order. Staff interviews confirmed that the electronic medical record did not prompt for blood pressure entry, resulting in inadequate monitoring.
A resident with multiple health issues, including cognitive impairment and severe pain, was mistakenly given three doses of Ambien by an LPN instead of the prescribed hydrocodone-acetaminophen for pain. The resident experienced altered mental status and uncontrolled pain, resulting in a hospital transfer. The error occurred due to failure to follow medication administration protocols and was not identified until after the resident's condition worsened.
A resident with multiple chronic conditions did not receive care in accordance with physician orders when a PRN Furosemide order was not clarified and was administered daily, and staff failed to notify the physician of persistent low blood pressures after a fall, despite explicit orders to do so. Documentation confirming physician notification was not provided.
The facility failed to maintain accurate nurse staffing information, affecting all 79 residents. Nurse Staff Posting forms did not document actual staff hours or update with each shift. Discrepancies were found between staff schedules and posting forms, with changes like call-ins and agency staff not reflected. Scheduler-C did not maintain 18 months of postings or update forms with staff changes, and some forms were unedited computer printouts. The new Nursing Home Administrator was informed but had no additional information.
A resident with a complex medical history, including diabetes, congestive heart failure, and dementia, experienced a choking episode and became unresponsive. Despite verbal consent for a Do Not Resuscitate (DNR) order from the resident's Power of Attorney (POA) and daughter, the necessary signatures from both the POA and the attending physician were missing. This incomplete documentation led staff to mistakenly believe the resident was a DNR patient, resulting in no CPR being administered. The facility's policy on CPR emphasizes the need for a fully signed DNR order, which was not in place, causing confusion during the emergency. The incident underscores the importance of ensuring complete and accurate documentation of advance directives.
An 82-year-old male resident with diabetes, congestive heart failure, dysphagia, and dementia required constant supervision during meals due to swallowing difficulties. Despite speech therapy recommendations, the facility did not update the care plan to reflect these needs. The resident was given a peanut butter and jelly sandwich in a lounge area with only partial supervision, as staff were occupied with other tasks. The resident began choking, and despite intervention attempts, he was pronounced deceased. The lack of adherence to supervision levels and swallowing strategies contributed to the incident.
The facility failed to follow professional standards for food service safety, as a dietary aide did not change gloves or perform hand hygiene when moving from the dirty to the clean side of the dishwashing machine, potentially affecting all 78 residents.
The facility failed to implement an effective Water Management Committee and did not include a closed unit in their water plan, potentially affecting all 74 residents. Additionally, an LPN was observed administering medications in an unsanitary manner by touching pills with bare hands.
The facility failed to complete annual performance reviews for five CNAs, potentially affecting all 78 residents. The Administrator confirmed the absence of a policy for performance reviews, and the last evaluations for the CNAs were conducted between 2021 and 2022. The Administrator acknowledged the expectation for annual reviews but was unsure if they were done yearly.
The Facility failed to ensure that 8 randomly chosen staff members received the required QAPI training within the mandated time-frame from their date of hire. This deficiency was identified during a review of training records and had the potential to affect all 78 residents in the facility.
The facility failed to ensure that staff received the required annual Compliance and Ethics training, affecting all 78 residents. Training records for Laundry/Housekeeping and Dietary Aide staff were missing or incorrectly recorded, as confirmed by interviews with the Dietary Manager and Housekeeping Supervisor. The issue was reported to the Administrator and DON, but no further information was provided.
The facility failed to provide required behavioral health training to direct and indirect care staff, including CNAs, an LPN, a laundry/housekeeper, and a dietary aide, despite admitting residents with psychiatric and mood disorders. A review of training records showed that none of the staff received the necessary training since their hire dates.
A resident with a Stage 4 pressure ulcer was observed with an air mattress set at an incorrect setting, contrary to medical orders. Despite instructions to set the mattress at 100 pounds, it was found at 300 pounds on multiple occasions, potentially impacting the resident's wound healing. The issue was only addressed after the surveyor's query.
A resident readmitted with a Foley catheter after hospitalization for acute cystitis with hematuria did not receive a timely follow-up appointment with urology as recommended. The facility failed to schedule the appointment within the recommended three-week period, leading to a delay in necessary medical care.
The facility failed to provide adequate nutritional support to two residents, resulting in significant weight loss. Despite dietician recommendations for weekly weights, the facility did not implement these orders, and meal intake documentation was inconsistent. Interviews revealed a lack of communication and follow-through on dietary recommendations and weight monitoring.
The facility failed to ensure the appropriate administration of intravenous fluids for a resident. The IV bag lacked identifying information, and there was no documentation related to the IV insertion site. The facility's policy on IV administration was not followed, and the RN acknowledged the discrepancies.
A resident with orders for oxygen humidification was observed receiving oxygen without a humidifier on multiple occasions. The RN/unit manager was unaware of the requirement, and the issue was addressed during the exit meeting. The resident was later observed with the humidification in place.
The facility did not ensure that two residents were free from unnecessary medications. One resident was prescribed Seroquel without a timely AIMS assessment, and another resident did not receive required AIMS assessments following multiple psychotropic medication changes. The facility's policy on AIMS assessments was not followed.
The facility failed to ensure proper labeling and storage of drugs and biologicals. Observations included expired supplements in the East medication room and improperly labeled or expired eye drops in the North team two medication cart. The Health Unit Coordinator/Scheduler was responsible for checking and disposing of expired medications.
A resident with a gastrostomy tube did not receive appropriate care as the water flush bag was not labeled or dated for two days. Despite physician orders and care plan interventions, the facility failed to ensure proper labeling, which was only corrected after the surveyor's observations.
The facility failed to notify the State LTC Ombudsman of hospitalizations for two residents. Despite multiple hospital admissions for serious conditions, the required notifications were not made due to confusion over responsibility, with the last notification sent in July 2023.
Inaccurate PBJ Staffing Data Submission Leads to Deficiency
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS for the first quarter of 2025 was accurate. During the review of the Payroll-Based Journal (PBJ) staffing data, the facility was flagged for excessively low weekend staffing, which had the potential to affect all 67 residents. The facility is licensed for 100 residents, with specific staffing requirements per shift and unit. Surveyors reviewed daily staff schedules and postings for the relevant period and confirmed that both Licensed Nurses and Certified Nursing Assistants (CNAs) were present on each shift and unit, with call-ins and replacements documented. Despite the presence of staff as per the schedules, the facility's PBJ data indicated low weekend staffing due to issues in how staff hours were reported and coded. The Scheduler stated that staffing was determined by census and acuity, and was unaware of the reason for the low staffing trigger, noting that unit managers were included in reportable staffing during the week but not on weekends. The Nursing Home Administrator later identified that training/orientation hours were not captured in the reporting, and that unit managers and the Infection Control Nurse, who were coded as direct care during the week, did not work weekends, resulting in a significant drop in reported direct care hours on weekends.
Failure to Document Water Management Activities for Vacant Unit
Penalty
Summary
The facility failed to provide adequate documentation demonstrating the implementation of an effective water management plan, specifically for the vacant south unit (rooms 101-123). According to the facility's own Water Management Program Policy, a risk assessment is to be conducted annually, utilizing data such as water temperature logs and rounding observation data. During the recertification survey, the surveyor requested documentation of weekly temperature testing and flushing logs for the south unit but was informed that these records were not completed or available for the period from January 2025 to June 2025. The facility was only able to provide observation data for other units, not for the south unit in question. The deficiency was further substantiated by interviews with facility leadership, who confirmed that the responsible maintenance staff had not completed the required monitoring or documentation for the south unit. The absence of these records meant that the facility could not demonstrate compliance with its own water management protocols, potentially affecting all 67 residents residing in the facility at the time of the survey. No additional information or documentation was provided to address the lack of monitoring for the specified period.
Failure to Discontinue Unnecessary Psychotropic Medication After GDR Recommendation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received the recommended gradual dose reduction (GDR) and discontinuation of a prescribed anti-anxiety medication, Lorazepam, as advised by the psychiatric nurse practitioner (NP). The resident, who was cognitively intact and had a history of anxiety disorder, diabetes, peripheral vascular disease, anemia, and chronic kidney disease, had no documented mood or behavior symptoms over multiple assessments. The facility's policy required regular review and reduction of psychotropic medications unless clinically contraindicated, with interdisciplinary team involvement and documentation of medication effects. Despite the psychiatric NP's recommendation to discontinue Lorazepam following a GDR, the order was not implemented. The NP documented the plan to discontinue the medication and communicated this to the unit manager, expecting the change to be completed the following day. However, the medication continued to be administered, and nursing staff consistently documented the absence of targeted behaviors that would justify ongoing use of Lorazepam. The care plan and behavior monitoring were updated, but the actual discontinuation order was not processed. Interviews with facility staff revealed a breakdown in communication and follow-through. The unit manager did not recall receiving a verbal order, and the social services director, who reviewed the NP's notes and updated the care plan, did not recall discussing the discontinuation recommendation. The psychiatric NP confirmed that medication changes are communicated during behavior meetings or directly to the nurse or unit manager, but no telephone order was written. This lapse resulted in the resident continuing to receive Lorazepam despite the absence of clinical indications and a clear recommendation for discontinuation.
Failure to Provide Required Bed-Hold Notification and Documentation During Resident Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge, as well as documentation of the bed-hold policy and the rate to reserve a resident's bed, for two residents who were transferred to the hospital on multiple occasions. According to the facility's own policy, residents and/or their representatives are to receive written information about bed-hold practices both at admission and at the time of transfer, including the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's own policies regarding bed-hold periods. The policy also requires that a signed and dated copy of the bed-hold notice be kept in the resident's file and that this information be provided to all residents regardless of payment source. For one resident with diagnoses including quadriplegia, depressive disorder, hypertension, and anxiety disorder, the medical record review revealed multiple hospital transfers due to acute medical issues such as abdominal pain and suspected bowel obstruction. On several occasions, the Bed Hold Policy and Notice of Transfer forms were either incomplete or missing entirely. Required sections such as the bed hold policy, time period for room reservation, current daily rate, and signatures were not filled out. There was no evidence that the resident or their representative received the written bed-hold policy and notice of transfer as required by facility policy. A second resident, who has acute and chronic respiratory failure, COPD, diabetes, hypertension, and depression, also experienced multiple hospital transfers for conditions including respiratory distress, anemia, and colon cancer surgery. The surveyor was unable to locate completed bed-hold policy and notice of transfer forms for several of these transfers. Interviews with staff revealed inconsistent practices regarding the completion and distribution of these forms, with some staff unaware of the required bed-hold rates and others not providing the forms at all. The resident and her husband both confirmed they did not receive the required documentation. The forms in use at the time were also found to be missing the daily bed-hold rate, contrary to policy requirements.
Failure to Monitor and Intervene for Bowel Elimination Needs
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including multiple sclerosis, aphasia, anoxic brain damage, and severe cognitive impairment, did not receive appropriate monitoring and intervention for bowel movements as outlined in their care plan. The resident was dependent on staff for all toileting and hygiene needs and was always incontinent of bowel and bladder. The care plan required staff to record bowel movements, report abnormalities, and notify the physician of any changes in bowel function, including no bowel movement for three days. Despite these interventions, the resident did not have a documented bowel movement for a period of nine days. During this time, there was no evidence that as-needed bowel medications were administered, nor was there documentation that the physician was notified of the absence of bowel movements. Nursing notes and the medication administration record confirmed that no bowel interventions were provided, and staff did not follow the established protocol for monitoring and responding to constipation. The facility's staff described a bowel program that should have triggered interventions after 48 to 72 hours without a bowel movement, but this was not implemented for the resident in question. The lack of intervention led to the resident being diagnosed with a possible small bowel ileus after presenting with vomiting, high tube feeding residuals, and minimal bowel sounds. The facility did not have a written bowel monitoring policy, and staff acknowledged that no as-needed bowel medications were given during the period of concern. The deficiency was based on the failure to provide appropriate treatment and services to monitor and address the resident's bowel elimination needs according to physician orders and the resident's care plan.
Failure to Provide Range of Motion Interventions for Resident with Limited Mobility
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including Multiple Sclerosis, aphasia, and anoxic brain damage, was not provided with appropriate treatment and services to maintain or improve range of motion (ROM) or to prevent further decline. The resident was assessed as having limited ROM in one upper extremity and both lower extremities, as documented in the Minimum Data Set (MDS). Despite this assessment, there was no care plan in place addressing ROM, and no interventions or exercises were observed during care to address the resident's limitations. The facility's policy requires that interventions, exercises, and therapy be provided based on comprehensive assessment to maintain or improve ROM, and that these interventions be documented in the resident's care plan. However, a review of the resident's care plans revealed that none included interventions for ROM. The Kardex and other care documentation also lacked any mention of ROM exercises or related care. Interviews with facility staff, including the Rehab Director, MDS Coordinator, and Unit Manager, confirmed that the resident was not on a therapy or restorative program for ROM, and that staff relied on therapy referrals only if a decline in activities of daily living (ADLs) was observed. Direct observation of care provided to the resident showed that Certified Nursing Assistants did not perform any ROM exercises during routine care, and staff indicated that such exercises were believed to be the responsibility of therapy. The lack of a restorative program and absence of a care plan or documented interventions for ROM resulted in the resident not receiving appropriate services to prevent further decline in ROM, as required by facility policy and professional standards.
Failure to Maintain Proper Catheter Bag Storage and Dignity
Penalty
Summary
A resident with chronic kidney disease, muscle weakness, and urinary retention was admitted to the facility and required the use of an indwelling urinary catheter for bladder elimination. The resident's care plan specified that the catheter drainage bag should not touch the floor and should be stored inside a dignity bag holder on the bed or wheelchair, with catheter care to be provided every shift. Despite these documented interventions, multiple observations by the surveyor on the same day found the resident's catheter bag uncovered and either resting on the floor next to the bed or hanging on the bed, with varying amounts of urine present. The Director of Nursing confirmed that catheter drainage bags should be covered for dignity purposes and was unable to provide additional information regarding the observed deficiencies.
Failure to Flush G-Tube Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including multiple sclerosis, aphasia, anoxic brain damage, and dysphagia, did not receive appropriate care during medication administration via a gastrostomy tube. The facility's policy requires that enteral tubes be flushed with at least 15 ml of water before administering any medications and after medications have been given. However, during direct observation, the LPN prepared and administered the resident's medications through the G-tube without flushing the tube with water prior to administering the first medication, specifically Vitamin D. The LPN did flush the tube between medications and after administration, but failed to perform the initial flush as required by policy. The resident was severely cognitively impaired, as indicated by a BIMS score of 0, and was dependent on tube feeding per physician order. The LPN acknowledged the omission when questioned, attributing it to a lapse in memory and nerves. The failure to flush the G-tube prior to medication administration was directly observed by the surveyor and was not in accordance with the facility's established procedures for safe and effective enteral medication administration.
Oxygen Therapy Not Administered per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with a history of asthma, anxiety disorder, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen was not provided respiratory care in accordance with physician orders. The resident's care plan and physician orders specified oxygen administration at 3 liters per minute (L/min) via nasal cannula. However, multiple observations by the surveyor over several days revealed that the resident's oxygen was consistently set at 4 L/min, contrary to the prescribed amount. The resident was observed in her room and in a wheelchair, receiving oxygen at the incorrect flow rate on several occasions. Interviews with the resident and staff confirmed the discrepancy, with the resident stating she believed she was receiving 3 L/min and an LPN acknowledging the order was for 3 L/min. The LPN adjusted the oxygen to the correct setting only after being informed by the surveyor. No explanation was provided by the facility as to why the oxygen was not administered according to the physician's orders, and the deviation from the prescribed flow rate persisted over multiple shifts before being corrected.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's care plan was not person-centered and did not specify the nature of the trauma, the resident's triggers, or individualized interventions. Although the facility's policy required a multi-pronged approach to identifying trauma history and developing individualized care plans in collaboration with the resident and relevant professionals, these steps were not adequately implemented for this resident. Documentation and interviews revealed that the resident had a history of PTSD, bipolar disorder, anxiety, depressive disorder, and dementia, and was cognitively intact. The care plan and related documents lacked specific information about the traumatic events, the resident's triggers, and appropriate interventions. Staff, including CNAs, the RN/Unit Manager, and the Social Service Director, were unable to articulate what the resident's trauma was, what might trigger the resident, or what specific actions should be taken to prevent re-traumatization. The psychologist's notes referenced the PTSD diagnosis and the intention to use trauma-informed approaches, but there was no evidence of direct communication or collaboration with the facility staff regarding individualized interventions. The resident's care documentation was updated only after surveyor inquiry, and prior to this, the care plan and bedside Kardex did not include trauma-specific information. Staff interviews indicated a lack of awareness and understanding of the resident's PTSD, triggers, and appropriate responses. There was also no evidence of interdisciplinary collaboration with the psychologist or use of their expertise to inform care planning. As a result, the facility did not ensure that the resident received trauma-informed, culturally competent care in accordance with professional standards and the facility's own policies.
Medication Administration Error and Failure to Reconcile Controlled Substances
Penalty
Summary
A medication administration error occurred when a nurse administered Zolpidem (Ambien), a hypnotic, instead of the ordered Hydrocodone-Acetaminophen 5-325 mg for pain to a resident on two separate occasions. The resident, who had multiple medical conditions including rib fractures, severe malnutrition, cognitive impairment, and chronic pain, was admitted with orders for both pain and sleep medications. The nurse failed to correctly identify and administer the prescribed pain medication, instead giving the resident Ambien, which was not intended for pain management. The facility's policy required nurses to verify medications three times before administration and to reconcile controlled substances at each shift change. However, the nurse did not follow these procedures, resulting in the administration of the wrong medication. The error was not detected during the required narcotic count and reconciliation at the shift change, as the counts of both Ambien and Hydrocodone-Acetaminophen did not match the documentation. The discrepancy was only discovered later when another nurse reviewed the narcotic records and noticed the error. As a result of the medication error, the resident experienced uncontrolled pain, altered mental status, and agitation, ultimately requiring transfer to the hospital for evaluation and treatment. The incident highlighted failures in medication administration, verification, and controlled substance reconciliation, as well as lapses in communication and documentation among nursing staff.
Failure to Monitor Blood Pressure Prior to Metoprolol Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was adequately monitored as required by physician orders. Specifically, a resident with a diagnosis of hypertension had a physician order for Metoprolol Tartrate 100 mg twice daily, with instructions to hold the medication if the resident's systolic blood pressure was less than 120. However, review of the resident's Medication Administration Records (MAR) for several months showed that blood pressure readings were not documented prior to the administration of Metoprolol, despite the order's explicit requirement. The MARs indicated that the medication was administered, but there was no evidence that blood pressure was checked at the required times. Interviews with nursing staff confirmed that blood pressure readings should be documented in the MAR before administering medications with such parameters. However, staff acknowledged that the necessary documentation was missing and that the electronic medical record system did not prompt nurses to take and record blood pressure prior to administration due to incomplete order entry. As a result, there was no assurance that the medication was withheld when the resident's systolic blood pressure was below the specified threshold, as required by the physician's order.
Significant Medication Error: Multiple Doses of Ambien Administered Instead of Pain Medication
Penalty
Summary
A resident with multiple medical conditions, including rib fractures, severe malnutrition, cognitive impairment, and chronic pain, was admitted to the facility with several medication orders, including hydrocodone-acetaminophen for severe pain and zolpidem (Ambien) for insomnia. The resident's care plans included specific interventions for pain management and monitoring for adverse effects related to hypnotic medications. The facility's medication administration policy required staff to verify medications three times before administration and to compare the medication label with the Medication Administration Record (MAR). On the evening and early morning hours in question, the resident received the scheduled dose of Ambien at bedtime. Subsequently, when the resident requested pain medication, an LPN administered Ambien instead of the ordered hydrocodone-acetaminophen on two separate occasions, resulting in the resident receiving three doses of Ambien within a ten-hour period. Documentation on the MAR and in progress notes indicated that the LPN signed out hydrocodone-acetaminophen but actually administered Ambien. The resident continued to complain of severe pain throughout the night, and the error was not identified until the following shift. As a result of receiving excessive doses of Ambien and not receiving the prescribed pain medication, the resident experienced altered mental status, agitation, and uncontrolled pain, leading to a transfer to the hospital for evaluation. Hospital records indicated the resident presented with rib pain, altered mental status, and hallucinations, with the likely cause identified as the administration of three doses of Ambien. The LPN involved later acknowledged being fatigued and unfamiliar with the new resident, which contributed to the medication errors.
Failure to Notify Physician of Persistent Low Blood Pressure and Clarify Medication Order
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including Parkinson's Disease, CHF, COPD, and chronic kidney disease, did not receive care in accordance with physician orders and professional standards. After a recent hospitalization for dehydration and acute kidney injury, the resident was discharged with a revised order for PRN Furosemide, to be administered only for edema or a 2-pound weight gain. However, the order was not clarified and was transcribed as a daily dose on the MAR, resulting in administration from 11/5/24 through 11/8/24. The DON later acknowledged the order was vague and not appropriate for PRN use, and could not confirm if the physician had been consulted to clarify the order. Following a fall, the resident exhibited persistently low blood pressures throughout the night. The physician had ordered that blood pressure be rechecked in one hour and to notify if not improving. Despite repeated low readings, there was no evidence that the physician was notified as ordered. The resident experienced another fall the next day and was sent to the emergency room. The facility was unable to provide documentation that the physician was notified of the ongoing low blood pressures, as required by the order.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to maintain accurate nurse staffing information, which has the potential to affect all 79 residents currently residing in the facility. The Nurse Staff Posting forms did not document actual staff hours and were not updated with each shift, as required. A review of the last 30 days of Nurse Staff Postings and working schedules revealed discrepancies, as the staff schedules did not correlate with the Nurse Staff Posting forms. The forms did not include actual hours worked by staff on each shift and contained irrelevant data. Changes such as call-ins, no call no shows, and the use of agency staff were not reflected on the Nurse Staff Posting forms. Scheduler-C, responsible for posting the Nurse Staff forms, did not maintain the last 18 months of postings and did not update the forms with staff changes. Scheduler-C admitted to not editing the actual staff hours to reflect who was present in the facility. During a three-week absence in September 2024, the forms were not updated. Some forms were merely printed from the computer without any edits to reflect staffing hours. The Nursing Home Administrator and Director of Nurses were informed of these concerns, but the new administrator did not have additional information.
Incomplete DNR Documentation Leads to Critical Incident
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure that a resident, identified as R127, had a fully signed Do Not Resuscitate (DNR) document in place. Despite verbal consent obtained from the resident's Power of Attorney (POA) and daughter, the necessary signatures from both the POA and the attending physician were missing on the Emergency Care Do Not Resuscitate Order (DNR). This lack of a valid DNR order led to a critical incident where R127 experienced a choking episode, became unresponsive, and was not breathing or pulseless. Facility staff did not administer CPR as they mistakenly believed R127 was a DNR patient due to the incomplete documentation. The report highlights that R127 had a complex medical history, including diagnoses such as diabetes mellitus, congestive heart failure, Atrial Fibrillation, kidney disease, peripheral vascular disease, right below knee amputation, dysphagia, and dementia. Despite the presence of a fully signed CPR consent form by the POA, the absence of a complete DNR order created confusion among staff during the critical event. The facility's policy on CPR clearly outlined the guidelines for providing basic life support, including CPR, in the absence of a signed DNR order, emphasizing the importance of adhering to residents' advance directives. The deficiency was further exacerbated by the lack of follow-up to ensure the completion of the necessary DNR documentation, as well as the failure to clarify the code status with the family in a timely manner. The report details the sequence of events leading up to the incident, including staff actions, communication with the family, and the subsequent emergency response by EMTs.
Supervision Deficiency During Meal Times for Resident with Swallowing Difficulties
Penalty
Summary
The report details a deficiency in a nursing home's supervision practices that resulted in a tragic incident involving Resident R127. R127, an 82-year-old male with multiple medical conditions including diabetes, congestive heart failure, dysphagia, and dementia, required constant supervision during meals due to swallowing difficulties. Despite recommendations from speech therapy for specific swallowing strategies and supervision requirements, the facility failed to update R127's care plan accordingly. On the evening of the incident, R127 was provided with a peanut butter and jelly sandwich in a lounge area approximately 20 feet away from nursing staff, with only partial supervision as the staff were engaged in other tasks such as charting. During the meal, R127 began choking on the sandwich, leading to a rapid deterioration in his condition. Nursing staff present at the time attempted to intervene with the Heimlich maneuver and suctioning, but their efforts were ultimately unsuccessful. Emergency services were called, and despite resuscitation attempts, R127 was pronounced deceased. The deficiency in supervision and failure to implement necessary swallowing strategies as outlined in the care plan directly contributed to the choking incident and subsequent tragic outcome for Resident R127. The facility's lack of adherence to the required supervision levels and swallowing strategies for R127, as indicated by the speech therapy recommendations and care plan, created a situation of immediate jeopardy. The failure to ensure adequate supervision during meal times, especially for a resident with known swallowing difficulties, highlights a critical lapse in care that resulted in a preventable accident.
Improper Hand Hygiene and Glove Use in Dishwashing Process
Penalty
Summary
The facility did not follow professional standards for food service safety, specifically in the handling of dishes and utensils after sanitization. During an observation, a dietary aide (DA-E) was seen moving from the dirty side of the dishwashing machine to the clean side without changing gloves or performing hand hygiene. DA-E was observed rinsing dishes, placing them in the dishwasher, and then handling clean dishes and silverware without changing gloves. When questioned, DA-E admitted to sometimes not changing gloves and only rinsing them before handling clean dishes. The dietary manager (DM-D) confirmed that gloves should be changed and hand hygiene performed when moving from dirty to clean areas. This issue was relayed to the Director of Nursing (DON-B), Nursing Home Administrator (NHA-A), and the President of Success-C during an end-of-day meeting. The failure to change gloves and perform hand hygiene when transitioning from dirty to clean dish areas was identified as a deficiency that could potentially affect all 78 residents receiving food from the kitchen.
Deficiencies in Water Management and Medication Administration
Penalty
Summary
The facility did not implement an effective Water Management Committee and failed to include a closed unit in their water plan, which has the potential to affect all 74 residents. The closed unit, which has been unused for years, was not identified in the facility's risk assessment, and there was no documentation of control measures for the stagnant water. The Maintenance Director confirmed the absence of a documented plan for the closed unit. The Water Management Committee reviewed their plan but did not address the closed areas on the South unit, although they had a plan for flushing water and taking temperatures in unoccupied rooms in open units. Additionally, the facility failed to maintain infection prevention during medication administration. An LPN was observed administering medications to a resident in an unsanitary manner by touching pills with bare hands before placing them in a medication cup. This practice was confirmed by the Director of Nursing and the Nursing Home Administrator, who acknowledged that nurses should not touch pills with their bare hands. No further information was provided to address this concern.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete performance reviews for five Certified Nursing Assistants (CNAs), which had the potential to affect all 78 residents in the facility. The Administrator informed the Surveyor that there was no policy and procedure for performance reviews of CNAs. An email from the Vice President of Human Resources confirmed that the facility did not have a formal evaluation process, although the employee handbook stated that supervisors would evaluate performance in writing at least annually. The facility assessment also required in-service training for nurse aides, addressing areas of weakness determined in performance reviews and facility assessments. The Surveyor requested performance reviews for five CNAs, revealing that the last evaluations for these CNAs were conducted between 2021 and 2022, with none completed within the past 12 months. The Administrator acknowledged the expectation for annual competency performance reviews but was unsure if they were done yearly. The Surveyor noted the concern that the facility did not complete performance reviews at least once every 12 months for the five CNAs, and no further information was provided by the facility at that time.
Failure to Provide Timely QAPI Training to Staff
Penalty
Summary
The Facility did not ensure that 8 of 8 randomly chosen staff members received the required Quality Assurance and Performance Improvement (QAPI) training on the elements and goals of the Facility's QAPI program. This training is mandatory for all direct and indirect staff. The deficiency was identified during a review of training records, which revealed that none of the sampled direct care workers, including CNAs and an LPN, nor the indirect care workers, including a Laundry/Housekeeping staff member and a Dietary Aide, had documentation of receiving the QAPI training within the required time-frame from their date of hire. The Facility's Facility Assessment Tool policy, updated on 3/28/24, did not list QAPI training as a required training for staff. Despite some staff members eventually receiving the QAPI training, it was not within the required time-frame based on their hire dates. The surveyor shared this concern with the Administrator and Director of Nursing, but no further information was provided at that time. The lack of timely QAPI training had the potential to affect all 78 residents in the facility.
Lack of Annual Compliance and Ethics Training
Penalty
Summary
The facility did not ensure staff received the annual Compliance and Ethics training, which had the potential to affect all 78 residents. The Facility Assessment Tool policy, updated on 3/28/24, did not include Compliance and Ethics training in the list of required trainings. Specifically, there was no documentation that Laundry/Housekeeping staff (LK-GG) and Dietary Aide (DA-HH) received the required training. LK-GG was hired on 10/27/18, and DA-HH was hired on 2/7/23. On 3/9/29, the surveyor reviewed the training records and found no evidence of the required training for these staff members. Interviews with the Dietary Manager (DM-JJ) and Housekeeping Supervisor (HS-KK) revealed that the training documentation was either missing or incorrectly recorded. The concern was shared with the Administrator (NHA-A) and Director of Nursing (DON-B), but no further information was provided by the facility at that time.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility did not ensure that direct care staff, including five CNAs, one LPN, and indirect care staff such as a laundry/housekeeper and a dietary aide, received behavioral health training to care for residents diagnosed with mental, psychosocial, a history of trauma, or substance use disorder as indicated on the facility assessment. The facility's policy requires staff to be competent in caring for residents with these conditions and implementing nonpharmacological interventions. However, a review of employee training records revealed that none of the mentioned staff members received the required behavioral health training since their hire dates, which ranged from 2017 to 2023. The facility's Facility Assessment Tool policy, updated on 3/28/24, indicates that the facility admits residents with various psychiatric and mood disorders and has an increasing number of residents with behavioral health needs and substance use disorders. Despite this, the facility did not list behavioral health training as a required competency for staff. This deficiency was confirmed during an interview with the Administrator and Director of Nursing, who were unable to provide further information or evidence of the required training being conducted for the staff in question.
Failure to Implement Accurate Pressure Injury Interventions
Penalty
Summary
The facility did not ensure that pressure injury interventions were accurately implemented for a resident (R57) who was observed with an air mattress set at an incorrect setting. Despite medical orders indicating that the alternating pressure relief air mattress should be set at 100 pounds and checked every shift, the mattress was observed set at 300 pounds on multiple occasions. This discrepancy was noted during observations on two consecutive days, and the setting was only corrected after the surveyor queried the staff. The resident's medical record indicated a weight of 84 pounds, and the incorrect mattress setting could have impacted the effectiveness of the pressure relief intervention. The resident had a history of a Stage 4 pressure ulcer on the sacrum, with wound assessments indicating a lack of significant healing and even some exacerbation over time. The wound consult assessments showed moderate serous exudate, slough, granulation tissue, and necrotic tissue, with the wound size and undermining increasing slightly over time. The plan of care included specific instructions for the air mattress settings, which were not followed, potentially contributing to the resident's ongoing wound issues. The surveyor raised concerns about the mattress setting during the facility exit meeting.
Failure to Ensure Timely Urology Follow-Up for Resident with Foley Catheter
Penalty
Summary
The facility failed to ensure that a resident received appropriate follow-up care after being discharged from the hospital with a Foley catheter. The resident was readmitted to the facility after a hospitalization for acute cystitis with hematuria and was discharged with a Foley catheter in place. The hospital discharge summary recommended a follow-up appointment with urology in three weeks for a possible trial void and cystoscopy. However, the facility did not schedule this follow-up appointment within the recommended timeframe. During an interview, the Registered Nurse Manager (RNM) confirmed that the resident had not seen urology prior to receiving a letter for an appointment scheduled for a later date. The Admissions Director (AD) also acknowledged that the follow-up appointment was missed and was only scheduled after the oversight was noticed. This delay in scheduling the necessary follow-up care constitutes a deficiency in providing appropriate catheter care and ensuring timely medical follow-up for the resident.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to provide adequate nutritional support to two residents, R21 and R66, as evidenced by significant weight loss and failure to follow dietician recommendations. R21 experienced a severe weight loss of 10.6% from December 2023 to March 2024. Despite the dietician's recommendation on March 11, 2024, to conduct weekly weights, the facility did not implement this order. The Unit Manager was unaware of the dietician's recommendation, and the last documented weight for R21 was on March 6, 2024. The dietician noted that supplement shakes were not initiated until February 9, 2024, despite R21's weight loss being evident on January 22, 2024. R66 also experienced significant weight loss, with a 15.7% decrease from October 2023 to February 2024. The facility's records showed inconsistent documentation of meal intake and failure to conduct weekly weights as ordered by the physician. The dietician was aware of the weight loss but did not ensure that weekly weights were consistently taken. The dietician also noted that R66 had sporadic changes in appetite and anxiety, which impacted her weight. Despite these observations, the facility did not consistently document meal intakes or follow the plan of care for R66. Interviews with the Unit Manager, dietician, and Nursing Home Administrator revealed a lack of communication and follow-through on dietary recommendations and weight monitoring. The facility's failure to adhere to its weight monitoring policy and the dietician's recommendations resulted in significant weight loss for both residents. The surveyor's findings highlighted the facility's deficiencies in providing adequate nutritional support and monitoring for residents at risk of weight loss.
Inappropriate Administration of Intravenous Fluids
Penalty
Summary
The facility did not ensure the appropriate administration of intravenous fluids (IVF) for a resident, identified as R57. The surveyor observed that the 1-liter bag of 0.9% sodium chloride being infused intravenously had no identifying factors such as name, date, rate, or purpose of the IVF. Additionally, the IV insertion site in the resident's right hand had no date to identify when it was inserted. The medical record review revealed inconsistencies in the documentation of the IV administration orders and the actual observations made by the surveyor. The Treatment Administration Record indicated the administration of sodium chloride intravenously every shift for hydration, but there was no documentation related to the IV insertion site in the resident's right hand. The facility's policy on Intravenous Fluid and Drug Administration General Policies, dated 8/21, requires the nurse to verify that the container's label coincides with the prescriber's order, including content, dose, prescribed rate, and expiration date of the solution. However, this policy was not followed in the case of R57. The Registered Nurse/Unit Manager (RN UM-M) acknowledged that there should have been an administration label on the IVF and that the IV administration orders did not align with the observations. The surveyor shared these concerns during the facility exit meeting.
Failure to Implement Oxygen Humidification
Penalty
Summary
The facility did not ensure oxygen humidification was implemented for a resident with orders for oxygen administration. The resident was observed on multiple occasions receiving oxygen via nasal cannula without a humidifier, despite having a physician's order to change oxygen tubing and humidifier bottles weekly. The registered nurse/unit manager was unaware of the humidifier requirement and thought it might be a batch type order. The issue was brought to the facility's attention during the exit meeting, and the resident was later observed with the humidification in place.
Failure to Conduct Timely AIMS Assessments for Antipsychotic Medications
Penalty
Summary
The facility did not ensure that two residents were free from unnecessary medications. Resident 72 was prescribed the antipsychotic medication Seroquel without a timely Abnormal Involuntary Movement Scale (AIMS) assessment. The surveyor reviewed Resident 72's medical record and could not identify any AIMS assessments completed by the facility when the antipsychotic medication was prescribed. During an interview, the Unit Manager stated that they do not usually complete AIMS assessments for residents and believed that the Director of Nursing (DON) was responsible for these assessments. The facility did not provide any additional information regarding the AIMS assessment for Resident 72 upon initiation of the antipsychotic medication. Resident 66 was admitted with diagnoses including hemiparesis, major depressive disorder, dementia, and anxiety disorder. Although an AIMS assessment was conducted upon admission, the facility failed to conduct subsequent AIMS assessments when psychotropic medications were increased and decreased. The surveyor noted multiple medication changes in Resident 66's plan of care, but the facility only provided the admission AIMS assessment dated 8/14/23. The facility's policy required AIMS assessments to be conducted upon admission, every six months, and with medication changes, but this was not followed for Resident 66.
Deficiency in Medication Labeling and Storage
Penalty
Summary
The facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the expiration date when applicable. During the survey, it was observed that the North team two medication cart contained containers of eye drops that were either not labeled with an opened date, had an illegible opened date, or were expired. Specifically, the cart contained an opened bottle of lubricant eye drops with an illegible date, an opened bottle of Brimonidine eye drops that was not dated, and an opened bottle of artificial tears with an illegible date. Additionally, a container of artificial tears with a resident's last name, who was no longer at the facility, was dated November 2023. Another resident had an opened bottle of Brimonidine Timolol Maleate 0.2% eye drops that was not dated, and another had an opened bottle of refresh tears eye drops that was not dated and an opened bottle of Ketotifen Fumerate eye drops that was dated 2/8/24. In the East medication room, the surveyor found 13 bottles of Optum Daily Rescue supplement that were expired as of August 2023. The Health Unit Coordinator/Scheduler was identified as the person responsible for checking the stock medications and disposing of expired medications. These findings were shared with the Director of Nursing, Nursing Home Administrator, and the President of Success-C, but no additional information was provided to address the concerns raised by the surveyor.
Failure to Label Water Flush Bag for Resident with Gastrostomy Tube
Penalty
Summary
The facility did not ensure a resident with a gastrostomy tube received appropriate care and services. The resident, who has a history of cerebrovascular accident (CVA) and dysphagia, was observed multiple times with an unlabeled and undated water flush bag. Despite physician orders specifying the administration of tube feeding formula, hydration, and flushes, the water flush bag was not labeled for two days. The resident's care plan included specific interventions for tube feeding and hydration, but these were not followed correctly as observed by the surveyor on several occasions. The surveyor noted that the resident's tube feeding was not running during multiple observations, and the water flush bag remained unlabeled and undated. An LPN confirmed that the water flush bag should be labeled with the resident's name and date, but this was not done until the surveyor brought it to the attention of the facility's staff. The Director of Nursing (DON) also acknowledged that the water flush bags should have a separate sticker for labeling. The deficiency was observed over a period of two days, indicating a lapse in the facility's adherence to proper labeling and care protocols for residents with feeding tubes.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to ensure the State Long Term Care Ombudsman was notified of hospitalizations for two residents, R10 and R51. R10 was admitted to the hospital on multiple occasions for various medical conditions including hyperkalemia, cellulitis, altered mental status, and acute cystitis. Similarly, R51 was hospitalized for a gastrointestinal bleed, critical lab results, and an unresponsive episode during dialysis. Despite these hospitalizations, the facility did not notify the Ombudsman as required. Interviews with the Social Services Coordinator and the Nursing Home Administrator revealed confusion about who was responsible for notifying the Ombudsman. The previous Nursing Home Administrator and Director of Nursing had been responsible for these notifications, but since their departure, the task had not been consistently performed. The last notification to the Ombudsman was sent in July 2023, and no notifications had been made since then, confirming a lapse in the facility's compliance with notification requirements.
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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