Amethyst Health Of Brown Deer
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 7500 W Dean Rd, Milwaukee, Wisconsin 53223
- CMS Provider Number
- 525498
- Inspections on file
- 41
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 54 (2 serious)
Citation history
Health deficiencies cited at Amethyst Health Of Brown Deer during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide and document ordered pressure ulcer care and prevention for three residents. A resident with severe cognitive impairment and total dependence for ADLs developed an in-house Stage 2 pressure injury on the posterior thigh, but weekly and daily skin assessments and the ordered daily wound treatment were not documented on multiple days, and the wound progressed to unstageable with 100% necrotic tissue without a thorough investigation or individualized care plan revision. Another resident admitted with an unstageable right heel pressure injury had hospital discharge wound care orders that were incorrectly entered so they did not appear on the TAR, and subsequent hospital-return wound orders were also not transcribed, resulting in several days without documented treatment until the wound physician wrote new orders. A third resident readmitted with an unstageable coccyx pressure injury had no coccyx treatment ordered or implemented for several days after return, the care-planned air mattress was not ordered or placed until days later, and the resident’s heels were observed not to be offloaded despite care plan interventions.
A resident with type 2 DM, CKD, and chronic diastolic CHF had an NP order documented in the EHR for daily weight monitoring, but the facility did not implement daily weights until several days later. EHR review showed a gap with no documented daily weights between the NP’s directive and the later physician order/start date, after which daily weights were recorded. The DON and NP both stated that NP recommendations, including daily weights, should be initiated by the following day, yet no evidence was found that this occurred during the identified period.
A resident with mild protein-calorie malnutrition and moderately impaired cognition experienced a documented drop in weight from 157.0 to 151.3 pounds over a short period. The NP entered a progress note indicating that the lower weight required a reweight for accuracy due to the significant decrease and expected the reweight to be completed within one day. The DON reported that NP recommendations, including reweights, are to be carried out within 24 hours and communicated to the unit nurse manager. However, surveyors found no evidence in the EHR that the resident was reweighed after the NP’s order, with the last recorded weight remaining at 151.3 pounds.
A resident with COPD and pulmonary hypertension was admitted with a hospital discharge order for 2 L/min oxygen at night, but the facility did not transcribe this order into the medical record. Admission documentation conflicted about whether the resident used supplemental O2, yet an oxygen care plan was initiated without specifying flow rate or frequency. Nursing notes later showed the resident receiving 2 L/min O2 via nasal cannula and then 3 L/min as documented by an NP, all without an active oxygen order. When an O2 order was finally entered, it only directed staff to titrate to keep SpO2 above 90% and did not specify flow rate or duration (continuous vs. nocturnal), and there was no documented ongoing monitoring to ensure the resident’s oxygen saturation remained above the ordered level.
A resident with diabetes, paraplegia, morbid obesity, ESRD on HD, and high pressure-injury risk developed multiple wounds while staff failed to provide consistent wound assessment, timely treatment orders, and accurate order transcription. The left breast wound was not comprehensively assessed when first found, later identified as pressure-related, and treatment changes were delayed or inconsistently documented. A new left hip wound and a right heel DTI also developed, daily diabetic foot checks were missed on multiple days, and an antibiotic order was entered incorrectly, causing missed doses.
Improper Disposal and Maintenance of Dumpster Area: Surveyors observed two dumpsters with lids open, garbage bags overflowing, and refuse scattered around the dumpster area, including cans, open bags, cups, lids, straws, gloves, soiled briefs/depends, towels, and broken cardboard boxes. The Dietary Mgr was unsure who managed the area, and the Maintenance Dir stated the dumpster area was shared with the apartment complex next door and that no one was currently managing it. The NHA stated the facility did not have a policy for maintenance of the outside garbage storage receptacles.
The facility's QAA Committee did not meet at least quarterly as required. Record review showed the committee met on two occasions but missed the final quarter of the year, and the NHA stated the missed meeting occurred because staff were out of the office. The deficiency was identified through surveyor review and interview and affected all residents in the facility.
The facility failed to maintain an effective infection prevention and control program. Staff were observed providing g-tube care and medication administration without proper hand hygiene and without required EBP gowns, a wound nurse left and re-entered a room multiple times with the same used gown during wound care, CNAs performed colostomy and catheter care without gowns for a resident on EBP and Contact Precautions, and an RT performed tracheostomy suctioning without a gown. The Water Management Program was also incomplete, with no current documentation showing where Legionella control measures were applied or that flushing and monitoring were being completed.
The facility did not ensure a designated IP worked at least part time at the facility for the Infection Prevention and Control Program. The DON was also serving as the IP while working DON duties and floor nurse shifts on the Ventilator Unit, and she stated she only dedicated limited days to infection prevention responsibilities. The facility assessment listed one full-time DON and one full-time IP, but the DON’s interview showed the IP role was not fully dedicated to infection prevention duties.
The facility failed to provide adequate supervision and accident prevention for several residents, including incomplete care planning, inadequate fall investigations, and insufficient smoking safety management. A resident with vertigo and cognitive impairment, assessed as high fall risk and recommended to use a 2WW with supervision, was repeatedly observed walking in hallways without a walker, while the care plan was not updated to clearly reflect current ADL status and supervision needs, and staff allowed ambulation based on how the resident "felt." Another resident who smoked had only sporadic smoking assessments, and neither assessments nor the care plan specified whether smoking should be supervised or whether the resident or staff should hold smoking materials, even though staff reported the resident smoked alone and kept personal smoking supplies. Two additional residents at high risk for falls experienced unwitnessed falls, one with facial bruising and one found on the floor despite being nonverbal and without bed mobility, and in both cases the facility’s fall investigations lacked clear timelines, detailed staff statements, identification of environmental or physiological contributors, root cause analysis, or documentation of what fall-prevention measures were in place at the time of the incidents.
The facility failed to provide required written transfer/discharge notices, bed-hold notices with the per diem rate, and Ombudsman notifications for multiple residents. Records showed several hospital transfers and one discharge without evidence of the required notices, and some bed-hold forms were incomplete. Staff stated Ombudsman notifications had not been sent for months, and one resident with a guardian had notices signed by the resident instead of the guardian.
MDS assessments were not completed or transmitted timely for multiple residents, including entry tracking, quarterly, modification to quarterly, and discharge assessments. Survey review of the EHR found missing accepted transmission dates or accepted dates outside the required window, and the Regional Nurse-D confirmed the assessments were completed or transmitted incorrectly.
Unlocked Medication Cart Left Unattended: Surveyors observed an LPN leaving a vent unit med cart unlocked and unattended during med pass, and the cart was also later observed unlocked and unattended in a public area. The facility policy required medication compartments to be locked when not in use, but 1 of 5 med carts was found unsecured, affecting medications for 10 residents.
Unlabeled and Undated Food Items in Unit Refrigerators: Surveyors found multiple opened food and drink items in 3 unit refrigerators and freezers that were not dated or labeled with resident names, including open drinks, take-out containers, grocery bags with food, and an opened bottle of thickened lemon water. The Rehab unit refrigerator log also had missing temperature entries, and the facility policy required resident foods to be labeled and opened beverages and containers to be dated and stored properly.
The facility failed to report an alleged incident of abuse to the State Agency within the required 2-hour timeframe. A resident with PTSD and intact cognition told an LPN that a CNA had grabbed the resident’s arm and that the resident felt the CNA’s nails on the skin. The LPN promptly informed the NHA and DON and, per the NHA’s direction, obtained a resident statement and performed a skin check. The NHA acknowledged receiving a text from the LPN about a resident reporting abuse late that evening but did not submit the allegation to the State Agency until the following morning, well beyond 2 hours after the allegation was made, contrary to the facility’s abuse prevention policy and federal requirements.
A resident with PTSD and intact cognition reported that a CNA grabbed the resident’s arm hard enough for the resident to feel the CNA’s nails on the skin. The facility’s abuse policy required interviewing the person who reported the incident, any witnesses, and involved staff, but the investigation did not include a statement from the LPN who first received the allegation or from an agency CNA who reported witnessing the interaction and said they had described it to the nurse on duty. The facility’s investigation conclusion referenced varying statements and could not conclusively determine the cause of a scratch, yet key interviews required by policy were not completed.
A resident with severe cognitive impairment and multiple comorbidities, fully dependent on staff for ADLs, had a care plan requiring staff-assisted showers twice weekly and toileting/check-and-change every 2 hours. Review of shower sheets and CNA task documentation showed several scheduled shower days with no recorded bathing or showering. Review of a 2-hour check-and-change log and CNA bowel/bladder documentation revealed prolonged periods with no documented checks or changes, despite the care plan requirement. Staff interviews confirmed expectations for twice-weekly showers and 2-hour continence checks but revealed inconsistent understanding of the purpose and duration of the paper logs. A social services staff member reported personally noticing the resident sitting in a common area most of the day and detecting an odor, consistent with concerns later raised by the family.
Failure to Assess Resident for Self-Administration of Medications: An LPN left a resident’s meds and applesauce at the bedside and exited the room without watching the resident take them. The resident had intact cognition and multiple chronic diagnoses, but the chart contained no self-administration assessment or documentation in the care plan, orders, MAR, or TAR showing the resident was approved to self-administer meds.
Inaccurate Code Status Documentation: A resident with significant cognitive impairment and an activated POA had conflicting advance directive records. The EMR dashboard and an active MD order showed full code, while signed DNR forms were also present in the chart. Staff gave inconsistent answers about the resident’s code status, and the code binder initially contained a full code order sheet for the resident.
A resident whose Medicare Part A coverage ended was not given the required written beneficiary notices, including the ABN and NOMNC. Surveyor review and staff interview showed the facility knew the forms had not been provided, and the BOM stated the DOSS was responsible for giving the notices and explaining appeal options.
A resident with dementia and psychotic disturbance was re-admitted on Zyprexa after the facility had previously completed a successful GDR and discontinued it. The facility did not follow up on why the hospital restarted the antipsychotic, and the record showed no behaviors or other documented clinical indication for continued use. The DON stated she was unsure why the medication was restarted and believed the resident did not need it.
MDS assessments were coded inaccurately for two residents. One resident's quarterly MDS showed anticoagulant use even though the resident was prescribed Plavix, an antiplatelet, and another resident with ESRD and hemodialysis had an annual MDS that did not document dialysis despite the resident's report and the MD order confirming treatment.
A resident with DM2, paraplegia, morbid obesity, CHF, and ESRD on HD developed new skin issues on the buttocks/gluteus. Facility staff did not complete comprehensive wound assessments when the wounds were found, did not enter a treatment order for the new gluteal wound until much later, and continued documenting treatment for a resolved wound while the active wound lacked consistent ordered documentation. The wound provider also could not always assess the resident during weekly rounds because of dialysis scheduling.
Inaccurate catheter and incontinence assessment and care planning. A resident with muscular dystrophy and ventilator dependence had conflicting documentation about Foley use, urinary continence, and catheter removal. Nursing notes referenced Foley removal and ongoing monitoring, while later provider notes stated a Foley was in place. Staff could not confirm a physician order for catheter use or discontinuation, and the care plan did not reflect the catheter status or a comprehensive urinary continence assessment.
Two residents did not receive adequate nutrition-related follow-up when weight changes were identified. One resident with MS, HTN, GERD, and other conditions had a significant 5%+ weight loss in one month, but the chart showed no physician or RD notification, no updated care plan, and no interventions. Another resident with protein-calorie malnutrition and dementia had highly inconsistent weights with large gains and losses, yet there was no documented re-weight, physician notification, or intervention, and the accuracy of the weights was not questioned.
Failure to provide trauma-informed care for 2 residents with PTSD. The facility did not complete trauma assessments or develop individualized care plans identifying PTSD triggers, monitoring, or interventions. One resident had a general psychosocial care plan but no trigger-specific interventions, and no trauma assessment was found in the record. Another resident had no PTSD care plan or trauma assessment, and staff were not aware of the resident’s triggers or what assessments were required.
Failure to monitor a resident’s psychosocial well-being after an abuse allegation. A resident with PTSD and intact cognition alleged a CNA grabbed the resident’s arm and used abusive language, but the EHR and 24-hour board had no documentation of increased checks or psychosocial/trauma assessments. The DSS stated such assessments would be expected after an abuse incident involving PTSD, but they were not completed because the allegation was not known to the department.
A resident with MS, polyneuropathy, neuromuscular bladder dysfunction, and brachial plexus injury had a monthly MRR that identified a duplication concern with Baclofen and Tizanidine. The pharmacist documented the recommendation and said it was emailed to the DON, but the EHR contained no physician response or documentation that the irregularity was reviewed and addressed.
A resident with multiple diagnoses, including DM2, osteomyelitis, colostomy, anemia, quadriplegia, and cognitive deficit, had no EMR documentation showing the influenza vaccine was offered, received, or declined. The DON stated immunizations are offered on admission and tracked through the WIR, but the record for this resident did not show influenza immunization status.
A resident with paraplegia, muscle weakness, and ESRD on dialysis had a call light that alarmed at the nurse’s station but did not light above the room door. The resident said the problem had been ongoing for about a week and that multiple staff had been told. Surveyor observations confirmed the malfunction, and the resident also had to call the receptionist for help after waiting for staff response.
A resident with severe cognitive impairment, ventilator dependence, incontinence, and high Braden scores was admitted and readmitted multiple times with evolving sacral pressure injuries and later additional buttock and heel injuries. The facility failed to develop an initial skin integrity care plan, omitted person-centered turning/repositioning and sacral off-loading interventions from the care plan and CNA Kardex, and did not create a monitoring plan when the resident was started on Eliquis for a DVT. Hospital discharge instructions and wound MD orders for specific sacral wound treatments (including Santyl, calcium alginate, and later 1/2-strength Dakins with foam-border dressings) were not consistently entered as MD orders or implemented on the TAR, and staff continued outdated treatments such as full-strength Dakins with ABD pads even as the wound progressed to Stage 4 with exposed bone and increased undermining. An ordered CT scan of the sacrum/coccyx to evaluate for osteomyelitis was marked as completed on the MAR/TAR, but there was no evidence it was scheduled or performed, and the resident was later hospitalized with sepsis and sacral/coccygeal osteomyelitis with abscess requiring debridement and partial coccygectomy.
A resident with severe cognitive impairment, anoxic brain damage, and chronic medical conditions was documented as always incontinent of bladder and dependent on staff for ADLs, yet later MDS assessments and the MAR showed use of an indwelling Foley catheter without any physician order, documented start date, or comprehensive care plan. Nursing staff recorded Foley output and monitored abnormal labs, and the resident was eventually transferred to the hospital with hypotension and increased oxygen needs, where septic shock secondary to UTI was diagnosed. After return, the catheter remained in use without timely orders or care planning, and only months later were specific catheter orders and a catheter-related care plan established. The DON acknowledged that staff likely accepted the catheter after a hospital stay without obtaining orders or assessing the need, and the facility’s failures were determined to have contributed to septic shock secondary to UTI from the indwelling catheter, resulting in an Immediate Jeopardy finding.
Surveyors found that the facility failed to maintain a full-time, dedicated DON when the census exceeded 60 residents. The Interim DON was splitting time between DON duties and working as a Clinical Manager/floor nurse on the vent/trach unit, while also serving as the facility IP, wound care supervisor, and lead educator. The ADON informally covered DON responsibilities without being formally scheduled as acting DON. PBJ data showed irregular DON hours spread across long days and weekends, not a consistent full-time weekday presence, and did not match the schedules described by leadership. The facility assessment listed separate full-time positions for DON and vent unit lead nurse, but in practice one person was performing both roles plus additional responsibilities, which surveyors noted was reasonably likely to have contributed to multiple clinical issues identified during the survey.
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and clear timetables for multiple residents with complex medical conditions, including those with intracranial hemorrhage, AFib on anticoagulants, chronic respiratory failure, anoxic brain injury, ALS, neuromuscular disease, and stroke. One resident on multiple antihypertensives and an anticoagulant lacked a care plan addressing BP and anticoagulant management, and the goals for neurological status and mobility did not match the identified problems. Other residents who were ventilator-dependent, had tracheostomies, G-tubes, indwelling catheters, and were always incontinent and dependent for bed mobility either had delayed initiation of key care plans (e.g., skin integrity and catheter care) or had care plans that omitted essential details such as how often they should be turned and repositioned or checked and changed for incontinence. CNAs reported relying on the Kardex for care directions, but these tools and the underlying care plans frequently lacked the specific, time-based interventions required by facility policy.
The facility failed to provide sufficient nursing staff on the ventilator unit, assigning only one CNA, one nurse, and one RT to care for 13 highly dependent residents, including multiple ventilator and trach patients who are always incontinent and require total assistance. Over a continuous five‑hour observation, several residents with chronic respiratory failure, anoxic brain damage, quadriplegia, ALS, myotonic muscular dystrophy, and comatose states were not observed receiving timely incontinence care or repositioning; when care was finally provided to some, their incontinence products and linens were saturated with urine and soiled with stool. Staff interviews confirmed that only one CNA is routinely scheduled for 11 residents on the vent unit, that the nurse focuses on meds and tube feeds and assists with care only when asked, and that respiratory staff do not routinely reposition residents. Leadership and the medical director acknowledged staffing challenges and agreed that having only one CNA for many fully dependent residents on the vent unit is problematic.
The facility failed to ensure that nurses and CNAs assigned to the ventilator unit had documented competencies in ventilator and tracheostomy care for residents requiring these services. The facility’s assessment referenced annual skills checks and as-needed training, yet review of schedules showed multiple RNs, LPNs, and CNAs regularly working on the ventilator unit without evidence of completed competencies, except for one LPN who had an in-service on suctioning and trach care. The NHA acknowledged that competencies were not consistently completed and that staff were assigned to the vent unit based on orientation, perceived strength, and prior work history rather than documented competency validation, and the ADON was unsure who was responsible for competencies. Despite a policy on staffing designation and role assignment, the facility could not produce competency records for the staff who worked on the ventilator unit during the review period.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and gloves for high-contact care activities for multiple residents with complex conditions including ALS, chronic respiratory failure, anoxic brain damage, dysphagia, quadriplegia, encephalopathy, and ventilator/tracheostomy and feeding tube dependence. Despite EBP signage and PPE carts at room doors, an LPN administered tube medications and performed suctioning wearing only a mask and gloves, CNAs provided incontinence care, hygiene, repositioning, and transfers wearing only gloves or no gown, and therapy staff assisted with transfers and bed mobility without gowns. One resident on EBP and contact isolation was repositioned by a CNA without gloves or a gown, and another resident on EBP had no EBP sign posted at the door. In an interview, the ADON described that gowns should be used for activities such as bathing, dressing, incontinence care, and transferring, but observed practices did not align with these expectations.
A resident admitted after an intracranial hemorrhage with multiple comorbidities required assistance with ADLs and used a walker and wheelchair, but the facility failed to complete a comprehensive baseline care plan within 48 hours of admission. The initial plan addressed issues such as hypertension, arrhythmia, bleeding risk, and neurological status but omitted key ADL needs, mobility details, and conditions related to depression, constipation, and anticoagulant use. Mobility interventions, including wheelchair use, were added much later, and there was no evidence that a written baseline care plan summary was provided to or reviewed with the resident, who reported that staff had not discussed or shared the care plan.
A resident with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer was admitted without documented skin issues but identified as at risk for skin concerns and needing moderate assistance with ADLs. After a shower, nursing notes documented multiple skin problems, including a left heel open blister and other peeling areas, with edema and pressure relief measures applied, and the NP notified. However, the treatment orders were not transcribed to the TAR, no comprehensive wound assessment with measurements was completed, and the care plan was not updated to address the new skin issues, contrary to the facility’s skin integrity policy. Days later, a wound MD documented a large venous wound on the left foot with unmeasurable depth and recommended increased level of care and antibiotics, and the resident was noted to be confused and was sent to the hospital.
A resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, and a G-tube was observed receiving tube feeding while lying flat in bed during personal care, contrary to the care plan and facility expectations that feedings be stopped and the HOB elevated during such care. The facility was unable to produce a tube feeding policy and instead provided an undated audit form stating the HOB should be elevated 30–45 degrees during feeding. A CNA lowered the resident’s HOB to flat without stopping the tube feeding and only placed the feeding on hold after being questioned by a surveyor, while the ADON later confirmed that staff are expected to stop tube feedings when providing care.
A resident with a history of intracranial hemorrhage, atrial fibrillation, hypertension, Parkinson’s disease, and other comorbidities had multiple ordered medications and BP/HR monitoring parameters in place, including scheduled antihypertensives, anticoagulant therapy, and PRN Hydralazine for elevated SBP. Review of the MAR and BP logs showed numerous missed doses of scheduled medications on multiple days, repeated failures to obtain ordered BP readings three times daily, and lack of PRN Hydralazine administration when SBP exceeded the ordered threshold, while Hydralazine was sometimes given when SBP was below the ordered hold parameter. The resident reported not always receiving medications, including on the day of admission, and noted missed BP checks. Staff interviews confirmed reliance on MAR documentation for refusals, difficulty identifying missed doses from bubble packs, and acknowledgment by nursing leadership of multiple missed entries without explanation.
Two residents admitted for rehab did not receive timely PT services in accordance with facility policy and their treatment needs. One resident with multiple serious conditions, including intracerebral hemorrhage and neurogenic bowel and bladder, remained in bed for several days after admission without PT evaluation, bariatric walker, or bariatric wheelchair, and reported having to use a urinal and have bowel movements in bed because staff did not know how the resident transferred or ambulated until PT evaluated. Another resident with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer was not screened by PT until two days after admission and did not have a full PT evaluation and plan of care initiated until three days after admission, then received only two PT sessions before hospital transfer. The Director of Rehab reported gaps in PT staffing, lack of a full-time PT, and difficulty obtaining PT coverage, which contributed to these delays and limited therapy provision.
Surveyors found that the facility failed to consistently post and maintain accurate daily nurse staffing information. On multiple occasions, no current staffing postings were displayed, and outdated postings remained in place. When postings were present, they lacked required elements such as the facility name, shift times, staff per unit, and actual hours worked or FTEs. The Scheduler, who also serves as HR assistant, reported shredding postings daily and not retaining any copies, and could not identify who was responsible for weekend postings. The NHA confirmed there were no policies for staffing postings, that no one was assigned to post staffing data on weekends, and that the required components of the postings were not fully understood.
A resident with diabetes did not receive daily foot checks or proper wound care as required by their care plan and facility policy, with missing documentation and failure to implement physician-ordered treatment. Additionally, another resident who experienced multiple unwitnessed falls did not receive complete neurological assessments, with several required checks missing from the records. These deficiencies were confirmed through staff interviews and review of facility documentation.
A resident with a history of respiratory failure and tracheostomy was placed on supplemental oxygen via nasal cannula after tracheotomy tube removal, but staff did not obtain a physician's order specifying oxygen administration details or update the care plan to reflect the new respiratory support. Documentation and staff interviews confirmed that oxygen was given without the required order or individualized care plan update, contrary to facility policy.
A resident with multiple complex medical conditions and impaired cognition experienced a systemic failure in hydration management, as the facility did not adequately assess, monitor, or intervene for fluid intake despite abnormal lab results and documented dehydration risk. Communication gaps between the NP, dietary, and nursing staff led to a lack of clear fluid intake goals and interventions, resulting in the resident's ICU admission for hypernatremia, acute kidney injury, and UTI.
A deficiency was identified when multiple staff and a contracted employee did not have documentation of required orientation and annual in-service training, as mandated by facility policy. The facility lacked a formal system for tracking and maintaining records of staff training, and there was confusion among leadership regarding responsibility for training oversight and documentation. This failure affected all staff roles reviewed, including dietary, housekeeping, nursing, and contracted personnel.
The facility did not provide or document required effective communication training for several direct care staff and a contracted employee, as mandated by policy. Leadership interviews revealed no system in place to track or ensure completion of this training, resulting in a lack of evidence that the necessary education was delivered.
The facility did not ensure that required abuse prevention, reporting, and dementia management training was provided to multiple staff and a contracted employee, as evidenced by missing documentation and lack of a tracking system. Leadership interviews confirmed the absence of an effective process to monitor and file training records, resulting in noncompliance with facility policy and potentially affecting all residents.
The facility did not ensure that all staff, including a dietary aide, housekeeper, RN, five CNAs, and a contracted RD, received mandatory QAPI training as required by policy. Review of employee records and staff interviews revealed no documentation of completed QAPI training for these individuals, and facility leadership acknowledged the absence of a system to track and document staff training.
Failure to Provide and Document Ordered Pressure Ulcer Care and Prevention for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure injury treatment and preventive services in accordance with standards of practice for three residents with actual or potential skin breakdown. One resident with severe cognitive impairment, quadriplegia, incontinence, and total dependence for ADLs was repeatedly assessed as high or very high risk for pressure injuries and had physician orders for weekly and daily skin assessments, as well as a treatment order for a newly identified Stage 2 pressure injury on the rear left thigh. Documentation on the Treatment Administration Record (TAR) showed that the ordered weekly skin assessments were not signed out as completed on multiple dates, and daily skin assessments and the ordered daily wound treatment were not documented as completed on several consecutive days following identification of the wound. Within four days, the wound that was initially documented as a Stage 2 pressure injury with 100% granulation tissue was re-assessed as unstageable with 100% necrotic tissue. The facility did not complete a thorough investigation or root cause analysis per its own policy to determine factors that led to the development and deterioration of this in-house acquired pressure injury, and the care plan for pressure injury risk was not revised with individualized interventions as the resident’s risk status changed. A second resident was admitted with an unstageable pressure injury to the right heel that was present on admission and had specific wound care orders from the hospital discharge paperwork. Nursing documented the presence and measurements of the unstageable right heel wound on admission, and the physician orders in the facility record included a daily Mepilex border dressing to the right heel. However, when the admission nurse entered the order into the electronic record, no time was selected, so the treatment did not populate onto the TAR and was not available for staff to sign out as completed. After the resident requested transfer to the hospital, emergency room documentation recorded the resident’s statement that wound care to the right heel had not been done. The hospital sent the resident back with new wound care orders for the right heel, but these orders were also not transcribed into the facility’s TAR. The first documented treatment to the right heel pressure injury did not occur until after the wound physician assessed the wound several days later and a new order was transcribed and started. A third resident, dependent for most ADLs, always incontinent, and identified as at risk for pressure injuries, had a care plan that included multiple pressure injury prevention and treatment interventions, including an air mattress and offloading of bony areas. This resident developed an unstageable coccyx pressure injury and a Stage 3 right buttock pressure injury that were documented by the wound physician prior to a hospital transfer. After readmission from the hospital, the resident returned with an unstageable coccyx pressure injury that had developed prior to hospitalization, but the coccyx wound treatment order was not entered until several days after readmission and was not implemented until two days after it was ordered. Although the care plan contained an intervention for an air mattress dated prior to hospitalization, the air mattress was not ordered until several days after readmission and was not placed on the bed until the following day. During observation, the resident’s heels were noted not to be offloaded, despite care plan interventions for offloading and pressure reduction devices. These actions and omissions demonstrate that the facility did not ensure timely implementation of ordered pressure injury treatments and preventive devices for this resident. Across all three residents, the survey findings show that the facility did not consistently complete or document required skin assessments, did not ensure that wound care orders (including those from hospital discharge instructions and in-house providers) were correctly transcribed onto the TAR, and did not timely implement ordered treatments and pressure-relieving interventions. For the resident with the in-house acquired thigh wound, the facility also did not follow its own policy requiring a thorough investigation and root cause analysis when a new in-house pressure injury was identified, and did not update the care plan with individualized interventions based on identified risk factors and changes in condition. These documented inactions and documentation gaps led to missed or unverified wound care and prevention measures for residents at high risk for pressure injuries or with existing pressure injuries.
Failure to Implement Ordered Daily Weights for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with a nurse practitioner’s order for daily weight monitoring for one resident. The resident was admitted with type 2 diabetes mellitus, chronic kidney disease, and chronic diastolic (congestive) heart failure, and had an admission MDS BIMS score of 15 indicating intact cognition. On 3/24/26, the resident’s NP documented in the EHR that the resident had chronic diastolic (congestive) heart failure and directed that daily weights be monitored, with a follow-up note to continue daily weight monitoring. However, the surveyor’s review of the EHR showed recorded weights on 3/20/26 and then not again until 4/3/26, followed by daily weights thereafter. The physician order for daily weights was dated 4/2/26 with a start date of 4/3/26, and there was no documentation that daily weights were obtained between 3/24/26 and 4/3/26. During interviews, the DON stated that when an NP makes recommendations after seeing a resident, these are given verbally or in writing to the unit nurse manager, and that if an NP requested daily weights, they should be initiated within 24 hours of the request. The NP reported that when they have a recommendation or new order, they notify the DON or one of the nurses and would expect daily weights to begin by the following day. The surveyor shared the concern with the DON and the NHA that the NP had requested daily weights starting 3/24/26, but the facility did not begin documented daily weights until 4/3/26, and no additional information was provided to account for the gap in implementation of the NP’s order.
Failure to Complete Ordered Reweight After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to follow through on a nurse practitioner’s (NP) order to reweigh a resident after a significant weight change. The resident was admitted with diagnoses including mild protein-calorie malnutrition and had a quarterly MDS showing a BIMS score of 12, indicating moderately impaired cognition. The resident’s electronic health record documented weights of 157.0 pounds on 3/23/26 and 4/5/26, and then 151.3 pounds on 4/6/26. On 4/9/26, the NP documented in a progress note that the 4/6/26 weight was 151.3 pounds and that a reweight was needed for accuracy due to the significant weight decrease, with a follow-up instruction to reweigh for accuracy. Surveyors were unable to locate any updated weight in the resident’s EHR after the NP’s 4/9/26 request, with the most recent weight remaining 151.3 pounds from 4/6/26. During interviews, the DON stated that NP recommendations are communicated to the unit nurse manager and that a requested reweight should be completed within 24 hours. The NP stated that when a reweight is recommended, it is communicated to the DON or a nurse and is expected to be completed within one day. Despite these expectations, there was no evidence that the facility completed the requested reweight, and no additional information was provided by the facility when the surveyor shared this concern with the DON and the Nursing Home Administrator.
Failure to Transcribe and Clarify Oxygen Orders and Incomplete Monitoring of Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate respiratory care by not properly transcribing and clarifying oxygen orders, and by administering oxygen without an active, complete order. A resident with COPD and pulmonary hypertension was admitted with a hospital discharge order for 2 L/min oxygen at night. On admission, facility documentation conflicted regarding the resident’s oxygen use: one admission tool recorded that the resident used oxygen and had an SpO2 of 90% on room air, while another clinical admission form documented that the resident did not use supplemental oxygen. No oxygen order from the hospital discharge summary was entered into the medical record at admission, and the oxygen care plan that was initiated did not include the ordered rate or frequency of oxygen use. Despite the absence of an active oxygen order, nursing documentation showed that the resident received oxygen at 2 L/min via nasal cannula and was later documented by an NP as being on 3 L of oxygen, increased from a home baseline of 2 L at night, with recent daytime oxygen needs and an SpO2 of 90%. An oxygen order was not entered until several days after admission, and that order only directed staff to titrate oxygen to keep SpO2 greater than 90% without specifying the flow rate or whether oxygen was to be continuous or nighttime only. The surveyor also noted there was no ongoing monitoring documented to determine whether the resident’s oxygen saturation remained above the ordered threshold, and interviews with the ADON, DON, and NHA confirmed that the hospital oxygen order had not been transcribed at admission and that oxygen was administered without a complete, active order in place.
Pressure Injury Care and Treatment Orders Not Consistently Followed
Penalty
Summary
The facility did not ensure that a resident at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing. The resident had diagnoses including type 2 diabetes, paraplegia, morbid obesity, congestive heart failure, muscle weakness, and end stage renal disease with hemodialysis. The resident was dependent on staff for all cares, mobility, and transfers, was incontinent of bowel and bladder, and had Braden scores of 15 indicating risk for pressure injuries. The care plan included pressure-relieving devices, heel floating, daily foot checks, and skin breakdown prevention interventions. When staff first identified a left breast wound, it was documented as an abscess with purulent drainage and a right upper buttock abrasion, but the initial wound assessment was not comprehensive and did not include measurements or tissue type as required by facility policy. The wound was not fully evaluated until two days later, and later wound documentation and interviews showed the left breast wound was considered pressure-related after the wound MD first assessed it in person. The record also showed discrepancies in wound etiology documentation, with the wound MD documenting infection, abrasion, or bacterial etiology in different notes despite stating in interview that the wound was pressure related. Facility staff also did not complete an ordered ultrasound or plastic surgery referral, and wound treatment orders were not always entered correctly or followed as written. A new skin issue on the upper right gluteus and a new left trochanter wound were identified, but treatment orders were not placed until weeks later. The wound MD found the left trochanter wound on the first in-person assessment and recommended treatment, yet facility staff did not enter the treatment order until later. The wound MD could not assess the resident weekly because the resident was at an off-site dialysis center during wound rounds, and the facility did not complete comprehensive weekly wound assessments when those appointments were missed. The facility also did not always update the care plan when wounds deteriorated. In addition, an antibiotic ordered twice daily for 14 days for the left breast wound was entered incorrectly as every 14 days, causing the resident to miss 7 doses. The resident later developed a facility-acquired right heel deep tissue pressure injury. In the days before that wound developed, daily diabetic foot checks were not documented on multiple dates. Staff and survey observations also showed the resident frequently leaned to the left in bed and in the wheelchair, and staff identified pressure as the cause of the left breast, left hip, and right heel wounds. The record further showed that wound dressings were not always in place during observation and that the resident’s wounds were not consistently documented as treated daily according to the wound MD’s orders.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
Dispose of garbage and refuse properly. Based on observation and interviews, the facility did not ensure the outside garbage storage receptacles were properly maintained and kept free of refuse. On 2/23/2026 at 9:15 AM, the surveyor toured the garbage area with the Dietary Manager and observed two large dumpsters with lids open, both full with garbage bags falling out and hanging over the sides. Behind both dumpsters were piles of garbage, including large cans, open bags of garbage, Styrofoam cups, plastic lids, and straws, and the surveyor could not see the ground behind the dumpsters because of the amount of garbage present. The surveyor also observed gloves, soiled briefs/depends, [NAME] body towels, hand towels, and broken cardboard boxes lying on the ground around the dumpster area, with some items not enclosed in garbage bags. The Dietary Manager was not sure which staff managed the dumpster area and stated it may be maintenance. On 2/24/2026 at 12:56 PM, the surveyor toured the area with the Maintenance Director, who stated the dumpster area was shared with the apartment complex next door and that there was currently no one managing the area because no one knew whether facility maintenance, apartment complex maintenance, or both were responsible. The Maintenance Director also confirmed concerns about the garbage surrounding the dumpsters and was unsure how often garbage was emptied. On 2/25/2026, the NHA stated the facility did not have a policy for the maintenance of the outside garbage storage receptacles.
QAA Committee Failed to Meet Quarterly
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee did not meet at least quarterly to identify and evaluate quality issues through assessment and assurance activities. Record review showed the QAA Committee met on 9/30/25 and 2/13/26, but did not meet during Quarter 4 of 2025. The deficient practice was identified as affecting all 63 residents in the facility. During interview on 2/26/26, the Nursing Home Administrator stated the facility meets quarterly but missed the last quarter of 2025 because staff were out of the office. The Administrator also stated the facility identified it was not compliant with the quarterly QAA Committee meeting requirement on 1/26/26. Surveyor review and staff interview confirmed the committee did not hold the required quarterly meeting for Quarter 4 of 2025.
Infection Control Program and PPE Failures
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program based on current standards of practice. Surveyors observed staff providing gastrostomy tube care for two residents in Enhanced Barrier Precautions (EBP) without wearing gowns and without performing appropriate hand hygiene after glove removal and before returning to the medication cart. The facility’s policy required hand hygiene before and after resident contact, before aseptic tasks, after contact with items in the resident’s room, and after removing gloves, and its EBP policy required gown and glove use for high-contact care activities such as feeding tube care. The facility’s Water Management Program was also found to be incomplete. Surveyors reviewed the program and could not locate documentation identifying where control measures should be applied based on where Legionella could grow and spread, or documentation showing a process to confirm the program was being implemented and was effective. The administrator stated the previous maintenance employee had left and that she had been implementing the program since September 2025, but the facility did not have current flushing logs or documentation showing routine flushing and monitoring had been completed. The administrator also stated the East unit had been reopened and housekeeping would complete water flushing, but no documentation was available. Surveyors observed additional PPE failures during resident care. During wound care for a resident with multiple wounds and an EBP order, the wound nurse wore a gown and gloves initially but left the room several times with the same used gown on and returned with the same gown to continue care. For another resident with EBP and Contact Precautions orders, CNAs provided colostomy and indwelling catheter care and repositioning without gowns, despite the posted precautions and the resident’s devices and wounds. For a resident with chronic respiratory failure, COPD, ventilator dependence, and tracheostomy status, a respiratory therapist performed suctioning and tracheostomy care while wearing gloves but no gown, even though the EBP sign outside the room indicated gown use for tracheostomy device care.
Infection Preventionist Not Dedicated to Infection Control Duties
Penalty
Summary
The facility did not ensure a designated Infection Preventionist worked at least part time at the facility to be responsible for the Infection Prevention and Control Program. The Director of Nursing was designated as the Infection Preventionist while also performing DON duties and working as a floor nurse on the Ventilator Unit, and this arrangement resulted in an inability to implement an effective Infection Prevention Control Program. The facility assessment dated 10/2023, last reviewed 02/2026, documented one full-time DON and one full-time Infection Preventionist. During interview, the DON stated she dedicated Mondays to infection prevention, worked two days per week on the Ventilator Unit as a floor nurse, and worked three days per week as the DON. She also stated she worked 10 days in two weeks and would dedicate 2-3 of those days to infection prevention responsibilities after a new interim DON started. The Nursing Home Administrator was notified of the concern that the facility did not have a dedicated full-time Infection Preventionist and acknowledged it.
Failure to Provide Adequate Supervision, Fall Investigation, and Smoking Safety Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents, including falls and smoking-related hazards, for multiple residents. One resident with encephalopathy, vertigo, mild neurocognitive disorder, chronic pain syndrome, and moderately impaired cognition (BIMS score 11) had been assessed as high risk for falls and was recommended by therapy to use a two-wheeled walker (2WW) with supervision for all mobility due to vertigo and cognitive impairment. The resident’s care plans referenced use of a 2WW with staff assistance for toileting and short distances and a wheelchair for long distances, but the care plan was not revised after the ADL evaluation and therapy discharge to clearly reflect the current level of assistance and supervision required. Surveyors repeatedly observed this resident ambulating in the hallway without a walker, and staff reported that the resident sometimes used a walker and sometimes did not, depending on how the resident felt, without consistent staff supervision or redirection to use the walker. Another deficiency involved a resident who smoked and had COPD, depression, and a cognitive communication deficit, with intact cognition (BIMS 14) and minimal assistance needs for ADLs. The facility’s smoking policy required evaluation of safe smoking status on admission and quarterly, including whether the resident could smoke safely with or without supervision and whether the resident could retain smoking materials. For this resident, only an admission smoking assessment and one quarterly assessment were located, and there were no documented quarterly smoking assessments for other quarters. Both available assessments and the smoking care plan lacked documentation specifying whether the resident was to smoke supervised or unsupervised and whether the resident or the facility should hold the smoking materials. Staff interviews indicated the resident typically went outside to smoke alone and retained personal smoking materials, and staff were unsure how often smoking assessments were to be completed or who was responsible for them. The facility also failed to thoroughly investigate falls for two other residents at high risk for falls. One resident with paraplegia, morbid obesity, and severe cognitive impairment (BIMS 4) had a documented fall in the room that was unwitnessed, resulting in a bruised left eye and nosebleed. The post-fall evaluation documented that the resident was reaching for items at the time of the fall, was wearing socks, and was not using prescribed assistive devices or oxygen, but the fall investigation form stated the resident was unable to describe the event, listed no predisposing environmental, physiological, or situational factors, and contained only a brief second-hand statement without clear identification of witnesses or staff involved. The investigation did not document when the resident was last seen, whether the fall was from bed, wheelchair, or chair, what fall-prevention interventions were in place at the time, or any root cause or new interventions. Another resident, in a comatose state with impaired range of motion in all extremities, dependent for all ADLs, and assessed as at risk for falls, was found face down on the floor next to the bed with an abraded area on the right forehead after an unwitnessed fall. Documentation later described the resident on the floor on the left side of the bed in a supine position with all equipment intact and no apparent injuries, and the resident was transported to the ER. The post-fall evaluation and fall investigation forms indicated no identified environmental, physiological, or situational predisposing factors and did not identify a root cause. Staff statements documented that two agency CNAs and a respiratory therapist had repositioned the resident shortly before the fall and then found the resident on the floor minutes later, with adaptive devices such as a low bed, wedges, and boots in use. The DON later described a possible mechanism involving coughing, air mattress positioning, and a loose sheet, but this explanation and a clear root cause were not documented in the formal fall investigation, and the facility could not provide additional information explaining how a resident without bed mobility fell from the bed.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility did not ensure that residents received required written transfer or discharge notices, written bed-hold notices that identified the reserve bed payment rate, or notification to the State Long-Term Care Ombudsman for hospital transfers and a discharge. The report identified seven residents reviewed for transfers or discharges who did not receive the required documentation or notification: R6, R3, R55, R7, R36, R8, and R78. R6 was transferred to the hospital multiple times. The facility could not locate written notice of transfer or bed-hold notices for two of the hospital transfers, and the bed-hold notice for a later transfer did not list the per diem bed payment rate. R6 had a legal guardian, but the notice in the record was signed by R6 instead of the guardian, and there was no evidence the guardian received the written notice. The facility also had no evidence that the Ombudsman was notified of R6’s hospitalizations. R3, R55, R7, R36, and R8 also had hospital transfers, but the facility did not provide evidence that the Ombudsman was notified of those hospitalizations. For R3 and R55, the bed-hold notices in the record did not document the per diem rate required to hold the bed. R55 was severely cognitively impaired, while R3 was cognitively intact. R7 and R36 had hospital transfers with no evidence of Ombudsman notification. R8 had two hospital transfers, and there was no evidence the Ombudsman was notified of either transfer. R78 was discharged to an assisted living facility, and the facility found no evidence that the Ombudsman was notified of the discharge. The record showed discharge orders and medication list were signed, and a progress note documented the resident’s daughter came to the facility and said the resident was being discharged that day and took the resident’s belongings. Facility staff stated the Ombudsman notifications had not been sent since August 2025, and the social services director stated the task had gotten away from them.
MDS Assessments Not Completed or Transmitted Timely
Penalty
Summary
The facility did not complete and transmit required MDS assessments for 6 of 8 residents reviewed, including entry tracking, quarterly, Medicare 5-day, modification to quarterly, and discharge assessments. The report identified missing or untimely transmission for R25, R28, R40, R44, R64, and R73. For R25, the entry tracking MDS and quarterly MDS were not transmitted; for R28 and R40, quarterly MDS assessments were transmitted outside the 14-day window; for R44, the modification to quarterly MDS was not transmitted; for R64, the entry tracking MDS was transmitted outside the 14-day window; and for R73, the discharge return anticipated MDS was not transmitted timely. On 2/25/26, the surveyor reviewed the residents’ EHRs and found that several assessments had no accepted transmission date documented, while others showed accepted dates beyond the required timeframe. The RAI 3.0 User’s Manual states that non-admission OBRA and PPS assessments must be completed within 14 days of the ARD and transmitted within 14 days of completion, and entry tracking records must be transmitted within 14 days of the event date. The Regional Nurse-D confirmed that all 6 assessments were completed or transmitted incorrectly and stated that she had been transmitting the facility’s MDS assessments for the last few months, but was not sure why the assessments were missed. The NHA was informed of the concerns and no additional information was provided.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys. Surveyors observed 1 of 5 medication carts unlocked and unattended in an area accessible to the public, with the deficient practice affecting the vent unit medication cart used for medications for 10 residents. The facility policy titled Medication Labeling and Storage, dated 8/1/25, states that medication storage and preparation areas must be maintained in a clean, safe, and sanitary manner and that compartments containing medications and biologicals are locked when not in use. On 2/24/26, a surveyor observed an LPN passing medications on the vent unit and walking away from the medication cart, leaving it unlocked and unattended during the morning medication pass. The cart was again observed unlocked and unattended at 11:33 AM, and the LPN was later observed leaving the cart unlocked and unattended again at 1:02 PM. On 2/26/26, the surveyor notified the NHA of the observations, and the NHA acknowledged the concerns.
Unlabeled and Undated Food Items in Unit Refrigerators
Penalty
Summary
The facility did not ensure that food was stored, prepared, and served under sanitary conditions in 3 of 3 unit refrigerators. On 2/24/26, the Vent Unit refrigerator was observed to contain open drinks, a take-out Styrofoam container, multiple Styrofoam cups with lids, and an opened bottle of thickened lemon water that was not dated or labeled with a resident name. The Vent Unit freezer also contained a Culvers bag and a cardboard box of food in grocery bags that were not labeled and not dated. On 2/26/26, the Rehab Unit refrigerator temperature log had missing entries for 2/16/26, 2/18/26, 2/21/26, and 2/24/26. The refrigerator contained multiple grocery bags with food, a used Dominos pizza box, and a Qdoba take-out bag with food that was not labeled with a resident name or dated. The freezer contained two opened water bottles, an opened and not sealed waffle bag with one waffle in it, and a grocery bag with contents that were not labeled with a resident name or dated. On 2/25/26, the North and [NAME] Unit refrigerator contained 2 Styrofoam cups with caps on, 2 grocery bags with content, and a pitcher of pink juice about 2/3 full that was not dated or labeled with a resident name. The facility policy titled Food Storage stated that foods belonging to residents are labeled with the resident's name, item, and use-by date, beverages are dated when opened and discarded after 72 hours, and other opened containers are dated and sealed or covered during storage.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of abuse was reported to the State Agency within the required 2-hour timeframe after the allegation was made. Facility policy, titled “Abuse Prevention Program” and effective 1/23/26, requires that all alleged violations involving abuse be reported immediately, but not later than two hours, to the State Agency and other appropriate agencies. Despite this policy, the Nursing Home Administrator (NHA) did not report an allegation of physical abuse involving a resident and a CNA until several hours after first being informed of the concern. The resident involved, identified as R6, had been admitted on 6/25/2015 with diagnoses including post-traumatic stress disorder and had a legal guardian. R6’s most recent MDS documented a BIMS score of 15, indicating intact cognition. On the evening of 2/9/26, around 7:30 PM, R6 reported to an LPN that a CNA had grabbed R6’s arm and that R6 felt the CNA’s nails on the skin. The LPN stated that shortly after receiving this report, the LPN contacted the NHA and the DON, asking what should be done. The LPN reported being instructed by the NHA to obtain a statement from the resident and perform a skin check, which the LPN completed and provided to the NHA. The NHA acknowledged receiving a text from the LPN around 11:00 PM on 2/9/26 asking what to do if a resident reports abuse, and directed the LPN to get a statement and send it. The NHA stated that no information about potential physical contact was received until the morning of 2/10/26 and that the allegation was reported to the State Agency at 6:16 AM on 2/10/26 via email after the reporting website was not working. Surveyor review of the Facility Reported Incident showed the initial allegation of abuse was submitted to the State Agency at 2:16 PM on 2/10/26. The surveyor determined that the facility did not ensure the alleged violation involving abuse was reported to the State Agency immediately, and not later than 2 hours after the allegation was made, as required by facility policy and regulatory requirements.
Failure to Thoroughly Investigate Alleged Physical Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an alleged incident of physical abuse involving resident R6 and CNA-BB, as required by the facility’s Abuse Prevention Program policy. R6, who has PTSD and a BIMS score of 15 indicating intact cognition, alleged that CNA-BB grabbed R6’s arm and that R6 felt CNA-BB’s nails on the skin. The facility’s policy requires that the individual conducting an abuse investigation interview the person reporting the incident, any witnesses, and staff on all shifts who had contact with the resident during the period of the alleged incident. The facility’s investigation conclusion stated that it was unable to conclusively determine that a scratch was from physical contact between R6 and CNA-BB due to varying statements, but that it was prudent to deduce the scratch occurred from the CNA making contact with the resident’s arm. Despite these requirements, the investigation did not include an interview or statement from LPN-AA, who first received R6’s report of the alleged abuse and notified the NHA and DON, nor from CNA-CC, an agency CNA who reported witnessing the interaction between R6 and CNA-BB and stated having explained what happened to the nurse on duty. LPN-AA reported that, after being informed by R6 of the alleged arm grabbing, LPN-AA contacted the NHA and DON and was instructed by the NHA to obtain a resident statement and perform a skin check, which was done and provided to the NHA. CNA-CC confirmed caring for R6 on the date of the incident and stated that the facility did not contact CNA-CC for a statement about the alleged incident. The surveyor confirmed that the facility’s submitted investigation lacked statements or interviews from both the reporting nurse and the witnessing CNA, and the NHA acknowledged that a statement from CNA-CC was not obtained.
Failure to Provide Scheduled Showers and 2-Hour Check-and-Change for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide required Activities of Daily Living (ADL) services, specifically bathing and toileting, to a resident who was fully dependent on staff for care. The resident had diagnoses including bladder cancer, cerebral infarction (stroke), Alzheimer’s disease, vascular dementia, and depression, and was documented as severely cognitively impaired and dependent on staff for all care, mobility, and transfers. The resident’s ADL care plan, initiated 4/14/22, required staff assistance of one person for bathing/showers, with showers scheduled twice weekly on Tuesdays and Saturdays, and instructions to offer an alternative if a bath or shower was refused. The facility’s ADL support policy required that residents unable to carry out ADLs independently receive appropriate hygiene and toileting assistance in accordance with the plan of care. Surveyors reviewed the resident’s shower and bathing documentation for December 2025, January 2026, and February 2026, including shower sheets and CNA task documentation. They identified multiple dates on which the resident was scheduled to receive showers but there was no documentation that bathing or showering occurred, specifically on four scheduled shower days in January and February 2026. Interviews with CNAs and the ADON confirmed that residents were supposed to receive showers twice weekly, that shower days and shifts were listed in a binder at the nurse’s station, and that CNAs were responsible for documenting showers or bed baths on shower sheets and in the electronic medical record (EMR), with nurses completing skin checks and forwarding completed shower sheets to the DON. The resident’s care plan also included a toileting intervention from the fall care plan to review and revise a toileting program with checks and toileting every two hours and as needed. Surveyors reviewed an every-2-hour check and change log dated 2/17/26–2/20/26 and found multiple blank rows with no documentation, showing that on 2/17/26 the resident was not checked or changed from sometime before noon until 10 PM (at least 10 hours), and on 2/18/26 from 6 AM until 2 PM (8 hours). CNA bowel and bladder documentation in the EMR showed long gaps with no entries, including over 15 hours on 2/17/26 and almost 17 hours between the evening of 2/17/26 and the afternoon of 2/18/26. Staff interviews revealed inconsistent explanations about the purpose and duration of the check and change logs, with some CNAs stating they had been used long term for every two-hour checks and an ADON stating they were short-term tools without a formal policy. The Director of Social Services reported personally noticing the resident sitting in the common area most of the day and detecting an odor, and later learning that the family had raised the same concern, supporting the surveyor’s conclusion that the resident was not checked and changed every two hours as care planned.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that 1 resident was assessed for self-administration of medications before medications were left at the bedside. On 2/24/26, a surveyor observed an LPN place the resident’s medications and applesauce on the bedside table and leave the room without watching the resident take the medications. The resident nodded yes when asked if medications were always taken independently. The resident had diagnoses including chronic respiratory failure, COPD, paroxysmal atrial fibrillation, chronic diastolic heart failure, chronic kidney disease, hypertension, anemia, PTSD, and unspecified convulsions, and had a guardian. The resident’s most recent MDS documented a BIMS score of 15, indicating intact cognition. Record review found no self-administration medication assessment in the EHR and no documentation in the care plan, orders, MAR, or TAR showing the resident was assessed as capable of self-administering medications. The facility policy stated residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, with the decision documented in the medical record and care plan. During interview, the RN stated there should be a formal assessment and documentation in the chart if medications could be left at bedside, but later confirmed there was nothing in the resident’s chart noting self-administration and no MAR or TAR task for it. The NHA was informed that the LPN had left the medications at the bedside and that no self-administration assessment was located.
Inaccurate Code Status Documentation
Penalty
Summary
The facility did not ensure the medical record reflected a resident’s accurate advance directive wishes. R55 had diagnoses including bladder cancer, stroke, cardiomyopathy, Alzheimer’s disease, vascular dementia, and depression, and the discharge MDS documented moderate cognitive impairment with dependence on staff for all care, mobility, and transfers. R55 also had an activated POA. The resident’s chart contained a signed DNR form, but at the start of survey the EMR dashboard and active MD order documented full code status. Survey review found conflicting code status documentation throughout the record. The EMR dashboard showed full code with a hyperlink to advance directives that opened a signed DNR order, and another DNR form was also present in the record. Despite this, an active order dated in the chart documented full code, while an NP note documented that the patient was DNR. The facility’s code binder at the nurse’s station also contained an undated full code order sheet for R55 when surveyors first checked it, and staff gave inconsistent responses about whether R55 was full code or DNR. Interviews with CNA-HH, CNA-JJ, and the DON showed confusion about the resident’s code status. CNA-HH stated R55 was DNR, while CNA-JJ initially thought R55 was full code because the resident still went out to the hospital for treatment. The DON stated R55 had been full code for a long time but was now DNR, then later confirmed with the POA that R55 was DNR and entered a DNR order in the EMR and code binder. At the beginning of survey, however, the record still showed an active full code order, full code on the dashboard, and a full code order in the binder, despite the presence of signed DNR documentation.
Failure to Provide Medicare Coverage Termination Notices
Penalty
Summary
The facility did not ensure that residents whose Medicare Part A benefits ended were provided with written beneficiary protection notifications. For 1 of 3 residents sampled for beneficiary notifications, R83 was not given a written Advance Beneficiary Notice (ABN) at the time Medicare Part A coverage ended. The report states that the Notice of Medicare Non-Coverage (NOMNC) is used to notify a resident or resident representative that Medicare Part A coverage is ending in two or more days, and that the ABN is used to notify the resident or resident representative of services Medicare A will no longer cover, the estimated cost of those services, and the available options and appeal rights. On 2/24/26, the Nursing Home Administrator provided the beneficiary notification paperwork for the sampled residents and verified that no ABN or NOMNC had been provided to R83, who was discharged to home on [DATE]. The administrator later provided documentation showing the facility recognized on 1/9/26 that a NOMNC and ABN had not been provided to R83. During an interview on 2/25/26, the Business Office Manager stated the Director of Social Services was responsible for providing NOMNC and ABN documentation to residents, and that either she or the Director of Social Services would provide the forms and discuss appeal options. She also stated the forms are scanned into the EMR and that she had not had recent or additional training regarding NOMNC or ABN forms.
Unnecessary Psychotropic Medication Use Not Supported by Clinical Indication
Penalty
Summary
The facility did not ensure that a resident who had not been using psychotropic medication was only given such medication when it was necessary to treat a specific condition that was diagnosed and documented in the clinical record. The resident had diagnoses including unspecified dementia with psychotic disturbance and depression, and had previously been prescribed Zyprexa. The facility completed a gradual dose reduction and discontinued the medication after the resident was doing well, with documentation that the resident had no behaviors observed in the 30 days reviewed. After the resident was hospitalized and then re-admitted, the hospital discharge summary and physician orders included Olanzapine (Zyprexa) 5 mg at bedtime for psychotic disorder. The facility did not follow up to determine why the medication had been restarted in the hospital, and the record contained no documented behaviors or other clinical indication supporting its use after re-admission. The resident’s point-of-care documentation for the past 30 days showed no behaviors observed, and progress notes contained no documentation of behavior concerns since re-admission. During interview, the DON stated she was not sure why the hospital put the resident back on the medication and said she did not think the resident needed it anymore because the resident was doing fine without it. The NHA was later informed that the facility had previously discontinued the medication after a successful gradual dose reduction, but there was no evidence the facility followed up on the restarted order or documented a clinical reason for continuing Zyprexa.
MDS Assessments Were Coded Incorrectly for Medication and Dialysis Status
Penalty
Summary
The facility did not ensure Minimum Data Set (MDS) assessments were coded accurately for 2 residents reviewed for MDS accuracy. For one resident, the quarterly MDS documented that the resident was taking an anticoagulant medication and did not document antiplatelet use, even though the resident was prescribed Plavix 75 mg daily and survey review confirmed Plavix is an antiplatelet medication, not an anticoagulant. The MDS coordinator stated that if the resident was prescribed Plavix, antiplatelet should have been coded yes and anticoagulant should not have been coded yes, and confirmed the MDS should have reflected antiplatelet use instead of anticoagulant use. For another resident with end stage renal disease and dependence on renal dialysis, the annual MDS did not document that the resident received dialysis. The resident was cognitively intact, told the surveyor they went to an outside dialysis center every Monday, Wednesday, and Friday, and the active physician order documented hemodialysis on those days. The MDS coordinator stated that dialysis should be coded on the MDS and acknowledged that the resident's annual MDS did not document dialysis.
Incomplete Wound Assessment and Delayed Treatment Orders
Penalty
Summary
The facility did not ensure that one resident received treatment and care in accordance with professional standards of practice when new skin issues were not comprehensively assessed and wound treatment orders were not entered or followed consistently. The resident was admitted with diagnoses including type 2 diabetes, paraplegia, morbid obesity, congestive heart failure, muscle weakness, and end stage renal disease requiring hemodialysis. The resident was cognitively intact, dependent on staff for all other cares, mobility, and transfers, and always incontinent of bowel and bladder. The care plan included pressure-relieving devices, heel floating, daily skin inspection, education on skin breakdown prevention, and following facility policies for skin breakdown treatment. Facility staff found a right buttock abrasion and documented it as a new skin issue, but the initial wound assessments were not comprehensive and did not include measurements or the percentage of tissue in the wound per facility policy. Later, staff documented a new skin issue on the upper right gluteus/right buttocks, but a treatment order was not entered until more than a month later. During that time, the record showed documentation of treatments for the earlier right upper buttock abrasion even after it had been resolved, while the newer right gluteal wound did not have an active MD order in the record and daily treatments were not documented as completed as ordered. The wound provider first assessed the resident’s wounds after the new skin issue had already been identified by facility staff, and the provider noted the wound as a non-pressure wound of the right buttock with a treatment plan of daily and as-needed dressing changes. The surveyor found that when the wound provider was unable to assess the resident weekly because the resident was at off-site dialysis during wound rounds, facility staff did not complete comprehensive weekly assessments. Interviews with staff confirmed that if a wound is found, the nurse should assess it, call the doctor, and obtain a treatment order, and the wound nurse stated the order for the right gluteus wound was not entered because it was forgotten. The wound physician stated that seeing and assessing the resident’s wounds was challenging because of the dialysis schedule and that the resident was typically out during weekly wound rounds.
Inaccurate catheter and incontinence assessment and care planning
Penalty
Summary
The facility did not ensure appropriate care and services for a resident with urinary incontinence and catheter-related needs. The resident had diagnoses including muscular dystrophy and dependence on a ventilator. The most recent quarterly MDS documented a catheter in place and urinary continence as not rated, while a quarterly bowel and bladder evaluation documented the resident as always incontinent of urine with functional incontinence. The resident’s care plan addressed incontinence related to impaired mobility and skin breakdown prevention, but it did not indicate that the resident had an indwelling catheter or that a Foley catheter had recently been discontinued. The medical record contained nursing notes stating the resident was being monitored after Foley removal, that the resident voided without difficulty, and that incontinence care was provided as needed. However, the surveyor found no physician order for the catheter, no order to discontinue it, and no evidence that the facility completed further assessment of the resident’s voiding patterns after the Foley was documented as removed. The record also contained later provider notes stating that a Foley catheter was in place, creating conflicting documentation about whether the resident had a catheter at all. During interview, an agency RN initially stated the resident had a catheter, then went to the room and observed no catheter or bag and said it may have been discontinued but she did not know when. The Nursing Home Administrator could not confirm whether the resident had a catheter, when it was removed, whether there were orders to remove it, or whether a comprehensive assessment of urinary continence had been completed. The Regional Nurse also stated she could not find evidence of a physician order for catheter use or discontinuation and questioned whether the resident ever had a catheter, despite documentation stating otherwise. By exit, the facility was unable to provide evidence that it had comprehensively assessed and accurately care planned for the resident’s urinary continence status.
Failure to Address Significant and Inconsistent Weight Changes
Penalty
Summary
The facility failed to ensure that two residents received necessary services related to weight loss and acceptable nutrition. For one resident, who was admitted with diagnoses including rhabdomyolysis, asthma, multiple sclerosis, hypertension, GERD, anxiety, and cognitive impairment, the record showed a 5.14% weight loss in one month. The resident’s admission weight was 177.1 pounds, and later documentation showed a weight of 168.0 pounds. Although the facility policy identified a 5% loss in one month as significant, there was no documented comprehensive assessment of the weight loss, no evidence that the physician or dietitian were notified, no care plan update, and no interventions implemented. The resident stated staff had told them they knew about the weight loss but had done nothing to address it, and the resident also reported not liking the facility food and not being asked about food preferences or offered nutritional supplements. The resident’s chart also contained inconsistent documentation related to weight monitoring and nutrition review. A progress note documented the resident’s weight as stable even though the recorded weights showed a decline. The surveyor could not find documentation that the physician or dietitian were notified after the significant weight loss was identified. The resident’s meal ticket did not list allergies, while progress notes documented a dairy allergy. The resident’s nutritional assessment noted fair appetite, set-up assistance with eating, and a plan to continue the current plan of care, but there was no documented follow-up tied to the later significant weight loss. For the second resident, who had diagnoses including protein-calorie malnutrition, unspecified dementia with psychotic disturbance, cerebral infarction, depression, acute kidney failure, and hypertension, the documented weights were inconsistent and showed large unexplained changes. The record reflected a weight of 174 pounds, then 214 pounds, then 220 pounds, then 222.4 pounds, and later 192.6 pounds. There was no documentation that the facility or the RD questioned the accuracy of these weights, no re-weighs were completed, no physician notification was documented, and no interventions were implemented. The RD stated that if a weight seemed off, a re-weight should be done, but the record did not show that this occurred for the documented weight changes.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility did not ensure trauma-informed care was provided for 2 residents with diagnoses of PTSD because it did not complete trauma assessments or develop person-centered care plans identifying triggers, interventions, or monitoring related to their PTSD. The facility policy titled Trauma-Informed and Culturally Competent Care stated that assessment should evaluate symptoms and identify triggers, and that individualized care plans should address past trauma and decrease exposure to triggers that may re-traumatize the resident. One resident, R6, was admitted with diagnoses including PTSD, adjustment disorder with mixed anxiety and depressed mood, and an unspecified disorder of adult personality and behavior, and had a legal guardian. R6’s care plan addressed ineffective coping and included general interventions such as allowing time to answer questions, consulting pastoral care or social services per preference, and monitoring feelings related to isolation, unhappiness, anger, and loss. Surveyor review found the care plan did not include individualized interventions to identify or reduce exposure to PTSD triggers, and no trauma assessment was located in the electronic record identifying R6’s triggers. The screening assessment to determine abuse and neglect factors also did not identify triggers. During interview, the DSS stated a trauma screening was supposed to be triggered quarterly, but it had not been triggered for R6, and the DSS was not aware of R6’s specific PTSD triggers. Another resident, R5, was admitted with diagnoses including major depressive disorder, PTSD, personality disorder, and aphasia following cerebral infarction. R5 was able to communicate by answering yes/no questions, was oriented to person, place, and time, and had an activated power of attorney. Surveyor review found no care plan related to PTSD, no documentation of triggers, and no trauma assessments in the chart to indicate what R5 experienced related to PTSD. When asked, R5 indicated staff had not sat down to talk about past events or traumas. The DSS stated R5 was stable and had good family support, but was not aware of R5 requiring trauma assessments or what triggers, monitoring, or interventions would be needed. The RN was also not aware of R5’s triggers or what assessments or interventions staff were to complete for a resident with PTSD.
Failure to Monitor Psychosocial Well-Being After Abuse Allegation
Penalty
Summary
The facility did not ensure monitoring or support of a resident’s psychosocial well-being and ongoing safety after an allegation of abuse was made. On 2/9/26, a resident with a history of PTSD and a legal guardian alleged that a CNA grabbed the resident’s arm and that the CNA’s nails made contact with the resident’s skin; the resident also alleged the abuse was physical and verbal in nature. The resident’s record showed a BIMS score of 15, indicating intact cognition, and the facility’s abuse policy stated that abuse may result in psychosocial outcomes such as fear, disturbed sleep, nightmares, withdrawal, depression, and other behavioral changes. Survey review found no documentation in the resident’s EHR of ongoing monitoring, increased checks, or psychosocial assessments after the allegation. The 24-hour nursing board for the resident’s unit did not include the resident’s name or any documentation of the alleged incident or monitoring from 2/9/26 through 2/21/26. The Director of Social Services stated that a psychosocial assessment and trauma assessment would be expected after an abuse incident involving a resident with PTSD, but confirmed these were not completed because the department was not aware of the allegation. The investigation file concluded the facility could not conclusively determine the source of the scratch but substantiated inappropriate use of language by the CNA, who was terminated.
No Documented Physician Response to Pharmacist Medication Review Recommendation
Penalty
Summary
The facility did not ensure the physician acted upon pharmacist recommendations for 1 resident, R33, after a monthly medication regimen review. The facility policy stated the consultant pharmacist performs a medication regimen review for every resident receiving medication, reviews the medical record for medication-related problems and irregularities, and provides a written report to the attending physician within 24 hours for any non-life-threatening irregularity. The policy also required the attending physician to document that the irregularity was reviewed and what action, if any, was taken, with copies maintained in the permanent medical record. R33 was admitted with diagnoses including multiple sclerosis, polyneuropathy, neuromuscular dysfunction of the bladder, and injury of the brachial plexus, and had a BIMS score of 15 indicating intact cognition. The pharmacist completed an MRR on 1/26/26 and recommended reevaluation of duplication of Baclofen 10 mg TID and Tizanidine 4 mg Q8H PRN. Survey review of the EHR found no documented physician response to that recommendation. The resident’s active orders later showed Baclofen 10 mg three times daily for muscle spasms and Tizanidine 4 mg every 8 hours as needed for muscle spasms. The Regional Nurse-D stated the facility did not receive an email with the pharmacist recommendations, so there was no record of a physician response, and the pharmacist confirmed the recommendation had been emailed to the DON.
Failure to Document Influenza Immunization Offer or Administration
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after surveyors found the facility did not ensure 1 of 5 residents reviewed, R72, was offered or administered the influenza vaccine. R72 was admitted to the facility with diagnoses including Type 2 Diabetes, osteomyelitis, colostomy, anemia, quadriplegia, and cognitive deficit. Surveyor review of R72's EMR found no documentation showing the resident was offered, received, or declined the influenza immunization. The DON stated she was responsible for the Infection Control Program, that immunizations are offered upon admission and included in the admission packet, and that she checks the Wisconsin Immunization Registry and enters immunization history into the EMR. The DON also stated the facility had 45 residents current with influenza immunization and 16 residents not current. The NHA was notified of the concern, and no additional information was provided.
Nonfunctioning Resident Call Light Indicator
Penalty
Summary
A working call system was not available in one resident’s room because the light above the resident’s door did not illuminate when the call light was activated. The resident was cognitively intact, had paraplegia, muscle weakness, and end stage renal disease requiring dialysis, and was dependent on staff for all care except set-up and clean-up assistance for eating and oral hygiene. The facility policy stated that call lights should be plugged in and functioning at all times and that defective call lights should be reported promptly. The resident reported that the call light had not been working properly since the prior week. When the resident pressed the call light, a red light appeared behind the bed and the alarm sounded at the nurse’s station, but the light above the resident’s door in the hallway did not light. Surveyor observations confirmed this on multiple occasions, and staff members acknowledged that the resident’s call light did not light above the door even though it alarmed at the nurse’s station. The resident also stated that multiple staff members had been told about the problem. During the survey, the resident had to call the receptionist for help after waiting about 10 minutes without staff response, and later stated the resident did not get up in time for a resident council meeting because staff did not assist in time. Maintenance staff stated they were not aware of any call lights not working and had no work orders for call lights, even though the resident’s call light malfunction was observed and discussed with staff. Surveyor observations also noted staff walking past the resident’s room while the call light alarm continued at the nurse’s station.
Failure to Implement and Follow Pressure Injury Orders for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure injury treatment and preventive services consistent with professional standards for a resident at high risk for skin breakdown. On admission, the resident had severe cognitive impairment, was ventilator-dependent with a trach and G-tube, was always incontinent of bladder and frequently incontinent of bowel, and was completely dependent on staff for mobility and transfers. Braden scores of 11 documented the resident as high risk for pressure injuries, yet no skin integrity or pressure injury care plan was developed on admission, despite facility policy requiring comprehensive assessment and care planning. The resident’s head of bed needed to be elevated for continuous enteral feeds, further increasing pressure injury risk, but the CNA Kardex and care plan lacked person-centered interventions for turning/repositioning or sacral off-loading, and the Kardex contained inaccurate or incomplete mobility information. After a hospitalization, the resident returned with an unstageable sacral pressure injury and specific wound care instructions from the hospital and wound physician. The facility entered a sacral wound treatment order incorrectly as “as needed” instead of daily and failed to document treatment on at least one ordered day. On subsequent readmissions, hospital discharge summaries and wound MD notes specified updated treatments (e.g., Santyl with Vashe-moistened gauze, calcium alginate, Dakins 1/2 strength, foam-with-border dressings), but these recommendations were not consistently entered as physician orders or implemented on the Treatment Administration Record. The admission skin assessments often lacked complete wound descriptors (e.g., percentages of slough and granulation, stage), and there was no documented wound nurse admission assessment with staging after certain readmissions. The facility continued to use outdated treatment orders (such as calcium alginate or full-strength Dakins with ABD pads) instead of the wound MD’s current orders for 1/2-strength Dakins and foam-with-border dressings, even as the sacral wound progressed to Stage 4 with exposed bone and increased size and undermining. As the sacral pressure injury deteriorated, wound MD documentation showed progression from unstageable to Stage 4 with 10% bone exposure and later 30% bone, and the resident also developed an unstageable pressure injury to the left buttock and deep tissue injuries to both heels. The skin care plan was not updated with new, person-centered interventions after the wound was staged as Stage 4, and still did not include specific turning/repositioning or sacral off-loading measures. When bone became visible, the wound MD ordered a sacral/coccygeal X-ray and, based on suboptimal imaging, a CT scan was ordered to rule out osteomyelitis. The CT scan order was marked as completed on the MAR/TAR, but there was no evidence in the EMR that an appointment was scheduled or that the CT was performed, and the receptionist responsible for scheduling outside appointments reported never receiving the CT order. The resident later required hospitalization, where imaging and consults identified sacral/coccygeal osteomyelitis with abscess and sepsis, and the resident underwent debridement and partial coccygectomy. Upon readmission after this hospitalization, the facility again mis-staged the sacral wound as unstageable and failed to update the TAR to reflect the wound MD’s orders for 1/2-strength Dakins and foam-with-border dressings, continuing instead with full-strength Dakins and ABD pads while the wound measurements increased. Throughout this period, the facility also failed to implement a care plan for monitoring the resident while on a blood thinner (Eliquis) initiated after a hospital-diagnosed DVT. Weekly wound evaluations by the wound MD documented ongoing changes in wound size, depth, undermining, exudate, and bone exposure, and multiple hospitalizations occurred for conditions including ventilator-associated pneumonia, septic shock, and sepsis secondary to sacral osteomyelitis with abscess. Despite these changes and the documented decline of the sacral wound, the facility did not consistently follow hospital discharge wound care instructions, did not reliably enter or implement updated wound MD treatment orders, did not document complete wound assessments on readmission, and did not revise the care plan to include individualized repositioning and off-loading interventions. These failures led surveyors to determine that the resident did not receive necessary care and services to promote healing and prevent new pressure injuries, resulting in an immediate jeopardy finding. The facility’s own policies required comprehensive admission/readmission skin assessments with descriptors, timely physician notification, appropriate treatment orders for each wound, and development and updating of person-centered care plans based on risk factors and changes in condition. However, the record showed missing or incomplete admission skin assessments, lack of staging by qualified staff at key points, failure to document or follow hospital and wound MD treatment recommendations, and absence of documented rationale for not following those recommendations. The CNA Kardex and care plan did not reflect the resident’s total dependence for mobility with clear repositioning instructions, and there was no evidence of consistent implementation of pressure-relieving interventions such as turning schedules and sacral off-loading, even as the resident’s wounds worsened and new pressure-related injuries developed. Surveyor interviews with nursing leadership and staff confirmed that the expected process was to verify and enter hospital and MD orders on admission, complete thorough skin assessments with measurements and descriptors, and involve the wound nurse for staging and full assessment. Nonetheless, the EMR lacked documentation of these processes being carried out as described. The CT scan ordered to further evaluate suspected osteomyelitis was not scheduled despite being marked as completed, and there was no documentation in the EMR to support that the test occurred prior to the resident’s subsequent hospitalization where osteomyelitis and abscess were confirmed. Collectively, these documented omissions and missteps in assessment, care planning, order entry, and treatment implementation formed the basis of the cited deficiency for failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to Assess, Order, and Care Plan Indwelling Catheter Leading to Septic Shock from UTI
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with urinary incontinence received a comprehensive assessment, physician orders, and care planning for an indwelling urinary catheter. The resident was admitted with severe cognitive impairment, anoxic brain damage, acute and chronic respiratory failure, COPD, heart failure, and was documented on the admission MDS and CAA as always incontinent of bladder and dependent on staff for all ADLs and incontinence care. A care plan was initiated for bladder incontinence related to anoxic brain damage, but there was no documented indication at admission for an indwelling catheter. Subsequent MDS assessments documented that the resident had an indwelling catheter, and the MAR instructed staff to record Foley output every shift, yet the medical record contained no physician order for the catheter, no documentation of when the catheter was first placed, and no comprehensive care plan addressing indications for use or required catheter care. Nursing notes showed abnormal lab results, including low hemoglobin and hematocrit, and an elevated WBC count initially attributed to recent prednisone use, with repeat labs ordered. Later, the resident was noted to be hypotensive with increased oxygen needs and secretions, and was sent to the hospital. The hospital discharge summary for that hospitalization documented treatment for septic shock secondary to UTI. When the resident returned from the hospital, there was still no order for the catheter and no care plan directing catheter care and treatment. Months later, a physician order was finally obtained for a 16 French indwelling catheter to promote wound healing, followed by an order to irrigate the Foley catheter twice daily, and only then was a catheter-related care plan developed. The DON later stated that she believed the resident had returned from an earlier hospitalization with a catheter and that nurses did not obtain an order or assess the need for its use, and that she had no explanation for the lack of assessment and orders. The facility’s failures contributed to the resident developing septic shock secondary to UTI due to the indwelling catheter, resulting in a finding of immediate jeopardy beginning on a specified date.
Removal Plan
- All facility nurses re-educated on ensuring that all residents with a foley catheter have an order for the foley catheter along with standard foley catheter orders such as catheter changes, catheter flushing, changing graduate, having a barrier under graduate when draining bag, changing catheter drainage bag, etc.
- Director of Clinical Services (DCS) to assist with providing and explaining re-education to facility nurses.
- DCS assisted with providing 1:1 education with Interdisciplinary team nurses to facilitate and ensure understanding and expectations of processes and policy related to catheter care/orders and to include updating care plans.
- DCS(s) will assist with updating/creating individualized care plans.
- Nursing staff re-educated to complete foley catheter care q shift and prn.
- Nursing staff re-educated about changing out catheter materials biweekly and prn.
- Policy used as reference and guide during training.
- All training to floor staff to be completed by their next working shift.
- Audits will be conducted by DCS or designee on admissions and re-admissions with foley catheters to ensure foley catheter diagnosis and care orders are in place and that foley catheters are care planned appropriately per policy.
- Audits will be conducted by DCS or designee to ensure competency and compliance with catheter care.
- Audits will be conducted to ensure compliance with changing out catheter care materials biweekly.
- DCS or designee will review/audit POC charting Monday through Friday (Monday will include 72 hr review) to review catheter care tasks not completed; ad hoc education will be provided as indicated by DCS or designee for catheter care tasks not completed.
- Audits will be reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education is needed until substantial compliance has been achieved.
Failure to Maintain a Full-Time, Dedicated DON While DON Also Covered Multiple Clinical Roles
Penalty
Summary
The deficiency involves the facility’s failure to maintain a full-time, dedicated Director of Nursing (DON) as required, particularly when the census exceeded 60 residents. Interviews and record reviews showed that from late July to late October and again from late November to the survey date, the facility did not have a full-time DON. Instead, the individual designated as DON was functioning in multiple roles, including Interim DON, Clinical Manager/floor nurse on the ventilator/trach unit, Infection Preventionist (IP), wound care supervisor, and lead educator. The facility assessment documented that the facility staffs a full-time DON and a full-time ventilator unit lead nurse, but in practice, one person was performing both of these roles along with additional responsibilities. During interviews, the Interim DON reported working only part of the week on DON duties and the remainder as Clinical Manager/floor nurse on the vent/trach unit, including every other weekend on the unit. The Interim DON estimated dedicating approximately 30–32 hours per week to DON responsibilities and confirmed also serving as the facility IP, spending Mondays on infection prevention while multitasking with DON or floor nurse duties. The Assistant DON stated that coverage for the DON role on days when the Interim DON worked the floor was handled informally through verbal communication and that the Assistant DON was not formally scheduled as acting DON. The Nursing Home Administrator acknowledged that the requirement is to have a full-time DON and confirmed that the Interim DON was splitting time between DON duties, floor nursing, and IP responsibilities. Payroll-Based Journal (PBJ) data provided by the facility showed that while weekly reported DON hours often exceeded 40 hours, they were spread across long individual days and weekends rather than reflecting a consistent, full-time, Monday–Friday DON presence. The PBJ hours also did not align with the schedule pattern described by the Administrator and Interim DON, raising concerns about the accuracy of the reported DON hours. The surveyor noted that the lack of a full-time, dedicated DON, combined with the Interim DON’s multiple concurrent roles (DON, vent unit lead nurse, IP, wound supervisor, and educator), meant that these roles could not be adequately performed within the hours worked and created a reasonable likelihood that this contributed to various clinical issues identified during the survey in areas such as care planning, infection control, wound care, staffing, tube feeding, catheter care, and staff competencies. The deficiency was cited as a Class B State citation related to failure to meet required DON staffing. The Medical Director and a nurse practitioner involved with the ventilator unit both confirmed that they understood the Interim DON to be the DON but were not aware of the extent to which the DON was also working on the floor and serving as IP. The nurse practitioner stated that the DON position is typically full time plus more and acknowledged understanding a concern if the DON had that many responsibilities. The Administrator provided a timeline showing that after the prior DON resigned, the Interim DON assumed the DON role while continuing other duties, a new DON was briefly hired and then went on leave and was terminated, and the Interim DON again resumed the DON role while still functioning as Clinical Manager/floor nurse, IP, and wound supervisor. Throughout this period, the facility’s average daily census was in the high 50s to mid-60s, exceeding the threshold at which the surveyor stated a full-time, dedicated DON is required.
Failure to Develop Comprehensive, Measurable Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for multiple residents, despite clear policy requiring such plans within specific timeframes after MDS assessments. The facility’s written policy states that an interdisciplinary team, in conjunction with the resident and/or representative, must develop a comprehensive care plan within seven days of the required MDS and no more than 21 days after admission, including measurable objectives, timeframes, and services to meet physical, psychosocial, and functional needs. Interviews with the DON and ADON revealed that admitting nurses create temporary care plans, MDS staff are responsible for baseline care plans, and floor nurses are expected to update care plans, but there were gaps in execution, including the absence of an on-site MDS coordinator and reliance on remote and regional staff. One resident with a history of intracranial hemorrhage, atrial fibrillation, hypertension, and multiple antihypertensive and anticoagulant medications did not have a comprehensive care plan addressing anticoagulant or blood pressure management. Although this resident had care plans for hypertension, arrhythmia, risk for bleeding, risk for decreased cardiac output, altered neurological status, impaired physical mobility, dehydration, and a no-added-salt diet, the care plans did not include monitoring for effectiveness and side effects of blood pressure medications and anticoagulant therapy. The goals for altered neurological status and impaired physical mobility were not aligned with those problem areas, focusing instead on skin integrity and pressure-relieving devices. The resident reported that staff had not reviewed the care plan or interventions with them. Another resident, admitted with anoxic brain injury, chronic respiratory failure, tracheostomy, ventilator dependence, gastrostomy tube, and hypotension, was assessed on admission as at risk for pressure injuries and dependent for mobility, but a skin integrity/pressure injury care plan was not initiated until approximately 10 weeks after admission. When the skin integrity care plan was eventually started, it did not specify how often the resident should be turned and repositioned, and there was no ADL care plan documenting transfer or bed mobility status. This resident also had an indwelling catheter documented on MDS, but a urinary catheter care plan was not initiated until about six months later. The bowel incontinence care plan for this resident, and the corresponding CNA Kardex, did not include how often the resident should be checked and changed for bowel incontinence, even though CNAs reported relying on the Kardex for direction on resident care. Several other residents who were always incontinent of bowel and/or bladder and dependent on staff for rolling left and right lacked care plan interventions specifying the frequency of incontinence checks and changes and repositioning. One resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, and a history of an indwelling catheter had bladder and bowel incontinence care plans that addressed peri care, clothing, staff assistance, and skin monitoring but did not state how often the resident should be checked and changed. Another resident with chronic respiratory failure, dysphagia, anxiety disorder, encephalopathy, gastrostomy tube, tracheostomy, and ventilator dependence had a bladder incontinence care plan without a defined frequency for incontinence care, no bowel incontinence care plan at all, and an ADL care plan that did not specify how often to reposition in bed or in the Broda chair. Additional residents with chronic respiratory failure, neuromuscular or neurologic conditions, feeding tubes, tracheostomies, ventilator dependence, and indwelling catheters were similarly affected. One resident with myotonic muscular dystrophy and chronic respiratory failure had bowel and bladder incontinence care plans that omitted how often to check and change for incontinence, and an ADL self-care deficit care plan that only stated to ensure proper positioning for comfort without specifying repositioning frequency. Another resident with ALS, chronic respiratory failure, dysphagia, and anoxic brain damage had an ADL care plan indicating total assistance by two staff to turn and reposition “as necessary,” but did not define how often repositioning should occur. A further resident with hemiplegia following stroke, chronic respiratory failure, hypertension, and atrial fibrillation had a bowel incontinence care plan that did not specify how often to check and change, and an ADL care plan that stated assistance by one staff to turn and reposition “as necessary” without a defined schedule. Across these cases, the surveyors found that the facility did not consistently translate assessed needs—such as incontinence, bed mobility dependence, catheter use, and complex medical conditions—into comprehensive, measurable, and time-specific care plan interventions.
Insufficient Vent Unit Staffing Leads to Missed Incontinence Care and Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the ventilator unit to meet residents’ care needs, particularly for incontinent care and repositioning. On the ventilator unit, staffing for a 12‑hour shift consisted of one respiratory therapist, one nurse (LPN), and one CNA for 13 residents (11 ventilator residents and 2 with tracheostomies), most of whom were fully dependent on staff for all care. The facility assessment described the ventilator unit as requiring a higher staff‑to‑resident ratio due to increased needs, yet the actual staffing pattern on the day of survey observation provided only one CNA for the unit. The scheduler confirmed that for 11 residents on the vent unit, she staffs one CNA, and that a second CNA is only added when census reaches 14–15 residents. During continuous observation from 8:36 a.m. to 1:40 p.m., the surveyor noted that multiple dependent residents did not receive timely incontinence care or repositioning. One resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, a feeding tube, and tracheostomy, who is always incontinent of bowel, was not observed receiving care until approximately 12:31 p.m.; at that time the incontinence product was saturated with urine and the resident had a bowel movement, and the sheet was soiled with stool. Another resident who is comatose, has chronic respiratory failure, encephalopathy, dysphagia, a feeding tube, tracheostomy, and is always incontinent of bowel and bladder, was not observed receiving incontinent care until 12:57 p.m., which was the first care observed for that resident during the five‑hour observation period. A third resident with myotonic muscular dystrophy, chronic respiratory failure with hypoxia, dysphagia, anxiety disorder, a feeding tube, tracheostomy, ventilator, and always incontinent of bowel, was not provided incontinence care and repositioning until 1:18 p.m.; at that time the incontinence product was saturated with dark yellow urine, the sheet under the resident was wet with urine, and there was a large amount of stool on the buttocks and rectal area. Additional residents with indwelling urinary catheters and bowel incontinence were not observed being checked for bowel incontinence or repositioned during the same five‑hour observation. One such resident, comatose and always incontinent of bowel with an indwelling catheter, had a care plan intervention to be checked every two hours and assisted with toileting as needed, yet the surveyor did not observe the CNA enter the room to provide bowel incontinence care or repositioning. Two other residents with chronic respiratory failure, quadriplegia or anoxic brain damage, feeding tubes, tracheostomies, ventilators, indwelling catheters, and always incontinent of bowel were likewise not observed receiving bowel incontinence care or repositioning during the observation period. The CNA assigned to the unit reported having 12–13 residents, most fully dependent, and stated that rounds are supposed to be every two hours but that she was alone with 13 residents and would “do the best she can.” She also stated that when hired she was told there would be two CNAs per shift on the vent unit, but recently there had only been one. Interviews with staff and leadership further described the staffing pattern and division of responsibilities that contributed to the deficiency. The respiratory therapist stated they are responsible for airway management and do not routinely reposition residents unless asked to help. The LPN on the unit stated that treatments are done at night, and that she is responsible for medications and tube feedings; she indicated she would assist with repositioning or continence care only if help was needed, and that such care was the CNA’s responsibility. The CNA stated that after initial early‑morning checks to ensure residents were “living and breathing” and to empty catheters, she considered her next check after breakfast as her second round, but acknowledged she did not complete two‑hour checks and changes, stating that residents were “not on a schedule.” The administrator confirmed that the unit was staffed with one RT, one nurse, and one CNA, and acknowledged that what the surveyor observed occurred under that staffing pattern. The scheduler confirmed that one CNA is routinely scheduled for 11 residents on the vent unit and that being down one CNA is not considered an emergency for which bonuses would be offered. The medical director acknowledged that the facility has challenges with hiring and retention and stated that CNAs can pull help from other areas and that teamwork is key. When informed of the five‑hour continuous observation during which multiple residents’ needs were not addressed, the medical director agreed that staffing one CNA on the vent unit for many dependent residents is an issue. CNAs working on the vent unit reported that staffing is challenging, that there is only one scheduled CNA on the unit at all times, and that most residents are dependent for all care, making it hard to complete all required tasks. They stated that two CNAs are needed on the vent unit to provide necessary care and mobility assistance for the 12–13 residents typically assigned.
Lack of Documented Ventilator/Trach Care Competencies for Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides working on the ventilator unit had the appropriate competencies and skill sets to care for all residents with ventilators and/or tracheostomies. The facility assessment dated February 2026 stated that RN, LPN, and CNA competencies were to be obtained and evaluated through annual skills checks and as-needed training for new or unique skill sets. Despite this, surveyor review of the daily nursing schedule from 1/11/26 to 2/9/26 showed multiple RNs, LPNs, and CNAs regularly assigned to the ventilator unit, where 13 residents with ventilators and/or tracheostomies resided, without documented evidence that these staff had been assessed for competency in ventilator or tracheostomy care. Record review revealed that only one LPN (LPN-RR) had documentation of an in-service on suctioning and tracheostomy care, dated 3/19/25. None of the other listed staff who worked on the ventilator unit during the review period had documentation of receiving this in-service. When the surveyor requested competencies for facility and agency licensed nurses and CNAs who worked on the ventilator unit between 1/11/26 and 2/9/26, the Nursing Home Administrator initially stated that the facility would not have those competencies and acknowledged that competencies were done only if something came up, and that the facility’s policy did not reflect a requirement to complete competencies for all staff. The facility’s policy titled "Staffing Designation and Role Assignment," last reviewed 10/21/25, described a standardized approach for staffing designation, including credential verification, orientation, mandatory in-service education, and role assignment consistent with licensure and job description, but did not specify how competency for specialized units such as the ventilator unit would be validated. In interviews, the NHA stated that staff were allowed to work on the ventilator unit based on formal orientation, perceived strength, and past work history, such as prior acute care experience. The ADON reported that in-services were provided for issues such as abuse allegations, new processes, or changes in orders, but was unsure who was responsible for competencies and stated she had not done any. When the NHA later indicated that competencies had been done about a year ago and was asked again to provide competencies for nursing staff who worked on the ventilator unit, no such documentation was provided to the surveyor.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for all seven observed residents on the ventilator unit. The facility’s EBP policy, dated 3/25/24, requires targeted use of gown and gloves during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, device care (including feeding tubes and tracheostomies/ventilators), and wound care. Despite posted EBP signage and availability of PPE carts at many room doors, staff repeatedly performed high-contact care activities wearing only gloves or, at times, no PPE other than a mask, contrary to the policy requirements. For one resident with ALS who is ventilator-dependent with a tracheostomy and feeding tube, an LPN administered medications via the feeding tube while wearing only a mask and gloves, without a gown, even though the resident was on EBP and had an EBP sign posted on the door. Later, a CNA provided personal care to the same resident, including changing soiled bedding and handling soiled linens, while wearing gloves but no gown, despite a PPE container being present on the door. The CNA also left the room wearing the same gloves to obtain clean linens from the clean linen cart before returning to the room and closing the door. For another resident with chronic respiratory failure, a feeding tube, tracheostomy, and ventilator, an LPN performed suctioning while wearing only a mask and gloves, without a gown, even though an EBP sign was posted outside the room. During therapy for this same resident, a PTA and a CNA entered the room wearing only gloves and no gowns while assisting the resident to sit on the edge of the bed and providing therapy. For a third resident with anoxic brain damage, respiratory failure, dysphagia, a feeding tube, indwelling urinary catheter, tracheostomy, and ventilator, a CNA entered the room, which had both EBP and contact isolation signs posted, and repositioned the resident in bed by removing bedding and adjusting pillows without wearing gloves or a gown, and without closing the door. Another resident with chronic respiratory failure, dysphagia, anxiety disorder, encephalopathy, a gastrostomy tube, tracheostomy, and ventilator had a PPE container on the door but no EBP sign posted. Staff, including a CNA, PTA, and RT, transferred this resident from a Broda chair to bed using a Hoyer lift while wearing only gloves and no gowns. For a resident with anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, a feeding tube, and tracheostomy, a CNA performed extensive incontinence care and hygiene, including washing the resident’s body, cleaning bowel movement from the perineal and buttock areas, changing soiled draw sheets, and restarting tube feeding, while wearing only gloves and no gown. A second CNA who assisted with repositioning and changing soiled linens also wore only gloves and no gown during this high-contact care. For a resident with chronic respiratory failure, encephalopathy, dysphagia, a feeding tube, and tracheostomy, a CNA prepared to provide incontinence care by moving a linen cart to the room and entering with gloves only, without donning a gown, despite an EBP sign and PPE cart outside the room. For another resident with myotonic muscular dystrophy, chronic respiratory failure with hypoxia, dysphagia, anxiety disorder, a feeding tube, tracheostomy, and ventilator, a CNA performed full incontinence care and linen changes while the resident’s incontinence product was saturated with urine and there was a large amount of stool present. The CNA cleaned the resident’s perineal and rectal areas, changed soiled sheets, applied barrier cream, and replaced the incontinence product, all while wearing gloves but no gown, even though an EBP sign and PPE container were posted outside the room. In an interview, the ADON stated that staff identify residents on EBP or isolation by signs outside the door and described that gowns should be worn for activities such as brushing teeth, grooming, bathing, dressing, incontinence care, and transferring, but the observations showed staff not wearing gowns during these high-contact care activities.
Failure to Complete and Communicate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete baseline care plan within 48 hours of admission for one resident. The resident was admitted following hospitalization for a left cerebellar intracranial hemorrhage and had multiple diagnoses including intracranial hemorrhage, dysphagia, morbid obesity, atrial fibrillation, heart disease, TIA, and cognitive impairment. The admission MDS documented that the resident used a walker and manual wheelchair and required substantial/maximal assistance with bathing, dressing, rolling, and was dependent on staff for toileting hygiene, with a BIMS score of 15 indicating intact cognition. Despite these documented needs, the baseline care plan initiated on the date of admission focused on hypertension, arrhythmia, risk for bleeding, risk for decreased cardiac output, altered neurological status, and later impaired physical mobility, but did not address the resident’s ADL needs. Surveyor review showed that the baseline care plan did not document whether the resident required assistance with toileting, dressing, eating, transfers, bathing, and personal cares. The care plan documented impaired physical mobility and use of a safety device wheelchair only later, with the wheelchair intervention dated 20 days after admission, indicating that the resident’s mobility needs were not addressed in the baseline care plan within the required timeframe. Additionally, the surveyor’s review of the electronic medical record did not reveal evidence that a baseline care plan summary was provided to the resident. Further record review identified active medication orders for constipation (polyethylene glycol and sennosides), depression (trazodone), and anticoagulation for atrial fibrillation (Eliquis). The baseline care plan did not include the resident’s concerns or needs related to depression, use of an anticoagulant, or constipation. During an interview, the resident stated that staff had not reviewed care plan interventions or provided a copy of the care plan. The DON reported that admitting nurses complete assessments and a temporary care plan for skin and falls, and that MDS staff, therapy, and regional nurses are involved in creating baseline care plans, but there was no evidence in the record that a complete baseline care plan, including ADLs and the identified clinical issues, was developed and shared with the resident within 48 hours of admission.
Failure to Timely Assess and Care Plan Venous Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and treatment and to complete a timely, comprehensive assessment and care plan for a resident’s venous wound. The resident was admitted with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer, and the admission assessment and MDS documented no skin issues, though the resident was identified as at risk for skin concerns and required moderate assistance with bathing, dressing, and bed mobility. On 1/10/26, a nurse’s note documented new skin issues discovered after a shower, including a left elbow abrasion with skin peeling, right elbow skin peeling, right thumb skin peeling, and a left heel open blister, along with +3 pitting edema to both feet and bilateral lower extremities elevated with a pillow and pressure relief boots applied. The note also documented that all areas were cleansed with normal saline and dressed with xeroform and foam, and that the on-call NP was updated. Despite these findings, the treatment orders were not transcribed to the Treatment Administration Record, a comprehensive wound assessment with measurements and skin type was not completed, and the resident’s care plan was not revised to address the new skin issues identified on 1/10/26. The facility’s policy on skin tears, abrasions, and minor breaks required documentation of causation, completion of a non-pressure form, physician and family notification, resident education if completed, resident tolerance of procedures, complications, refusals, and preventive interventions, as well as completion of an incident/accident report when such issues were discovered. On 1/12/26, the wound MD assessed the resident and documented a venous wound to the left foot measuring 10 by 80 cm with unmeasurable depth due to dried fibrous exudate and recommended increased level of care and oral antibiotics for cellulitis. The same day, nursing notes documented that the resident was confused and not behaving normally, and the resident was sent to the hospital. The DON later acknowledged there was no comprehensive assessment until 1/12/26 and no baseline care plan related to skin integrity until 1/13/26, and stated she believed nurses were waiting for the wound MD to assess the wound.
Improper Management of Enteral Feeding During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate treatment and services for a resident receiving enteral nutrition. The facility could not provide a tube feeding policy when requested by the surveyor and instead produced an undated tube feeding audit form that stated the head of the bed should be elevated 30–45 degrees during feeding. The resident involved had significant medical conditions, including anoxic brain damage, dysphagia, chronic respiratory failure, quadriplegia, and pneumonitis due to inhalation of food and vomit, and required G-tube feeding to maintain adequate caloric and nutritional status. The resident’s care plan, initiated and revised in April and May, directed staff to hold tube feeding during care, turning, and repositioning, and to resume feeding when complete with the head of bed elevated. During an observation of personal care, a CNA entered the resident’s room, donned gloves, and lowered the resident’s head of bed to a flat position while the Nepro 1.8 tube feeding continued to run at 45 ml. The CNA removed the resident’s gown and requested a respiratory therapist to check the resident’s trach collar, which was then tightened before the therapist left the room. The CNA did not stop the tube feeding before lowering the head of the bed and only placed the feeding on hold after the surveyor questioned the ongoing feeding while the resident was lying flat. Later, when asked, the ADON stated that the expectation when providing care to a resident with a running tube feeding is to stop the feeding, confirming that the observed practice did not meet facility expectations or the resident’s care plan directives.
Failure to Administer Ordered Medications and Monitor Blood Pressure as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and monitoring to meet the needs of a cognitively intact resident with multiple serious medical conditions. The resident was admitted following a hospitalization for a left cerebellar intracranial hemorrhage and had diagnoses including intracranial hemorrhage, dysphagia, morbid obesity, atrial fibrillation, heart disease, TIA, Parkinson’s disease, and cognitive impairment. The resident’s admission MDS documented use of a walker and manual wheelchair, substantial/maximal assistance needs for ADLs, and dependence on staff for toileting hygiene, with a BIMS score of 15 indicating intact cognition. The facility’s policy on Medication Orders required that current orders be maintained in the clinical record, with clear specifications for type, route, dosage, frequency, and strength, and that PRN orders include the reason for administration. Surveyors reviewed the resident’s physician orders, which included multiple scheduled medications for hypertension, hyperlipidemia, insomnia, constipation, depression, Parkinson’s disease, and atrial fibrillation, as well as orders for BP and heart rate checks three times daily and PRN Hydralazine for elevated systolic blood pressure. Despite these orders, the Medication Administration Record showed numerous missed scheduled medications on multiple dates in January and February, including Amlodipine, Atorvastatin, Melatonin, Polyethylene Glycol, Trazodone, Amantadine, Carvedilol, Eliquis, Lisinopril, Sennosides, and Hydralazine. The resident reported not always receiving scheduled medications and specifically not receiving medications on the day of admission. The resident also stated that some scheduled blood pressure medications had not been received and expressed concern about frequent missed medications, though the resident could not provide exact dates and times. Surveyors further identified failures in blood pressure monitoring and PRN medication administration. The BP log and MAR showed multiple missed BP readings across many days in January and February, despite an order to check BP and heart rate three times daily. On at least one occasion, the resident had a documented systolic BP greater than 175 without PRN Hydralazine being administered as ordered. Conversely, Hydralazine was administered several times when the systolic BP was less than 130, during a period when the order specified it should be held if SBP was below 130. Interviews with the NP revealed that she relied on BP readings recorded via a BP machine linked to the resident’s cell phone, but the resident stated they could not perform BP checks independently and required staff assistance, with the BP machine observed out of reach at the bedside. Interviews with an LPN and the ADON confirmed that missed medications could not be identified by looking at bubble packs and that staff were expected to document refusals or unavailability in the MAR or progress notes. Review of the MAR and BP logs with the ADON confirmed multiple missed medication administrations, missed BP checks, and lack of PRN Hydralazine use when indicated, with no explanation provided by facility leadership.
Delayed and Insufficient PT Services for Two Rehab Admissions
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized rehabilitative services, specifically PT, in a timely manner for two residents admitted for rehabilitation. Facility policy states that therapy evaluations and services are to be scheduled and conducted in accordance with the resident’s treatment plan and Medicare guidelines, with therapy coordinated with nursing and documented in the medical record. Despite this, both residents experienced delays between admission and initiation of PT services, and therapy recommendations to nursing were not made until several days after admission for one resident. One resident was admitted with multiple serious diagnoses, including intracerebral hemorrhage, dysphagia, morbid obesity, atrial fibrillation, heart disease, neurogenic bowel and bladder dysfunction, chronic kidney disease, edema, TIA, and cognitive impairment. The admission MDS documented the resident used a walker and manual wheelchair and required substantial to maximal assistance with ADLs and was dependent for toileting hygiene, while remaining cognitively intact. The resident’s CAA noted that the resident was working with therapy for increased independence with ADLs, and staff were to provide assistance and monitor for changes. However, the EMR shows that therapy-to-nursing recommendations were not completed until four days after admission, and PT did not evaluate the resident until that date. In interview, the resident reported not being evaluated for multiple days, remaining in bed over a weekend until therapy was available, and lacking a bariatric walker and wheelchair for several days, resulting in use of a urinal and bowel movements in bed because staff did not know how the resident ambulated or transferred until PT evaluated. The second resident was admitted for rehabilitation with hepatic encephalopathy, alcohol cirrhosis with ascites, and pancreatic cancer, and the admission MDS documented the resident was cognitively intact and needed moderate assistance with bathing, dressing, and bed mobility. PT screened the resident two days after admission and identified the need for a standard wheelchair and two-wheeled walker with assistance of one staff for transfers. The PT evaluation and plan of treatment, completed three days after admission, ordered PT five times per week for four weeks, including therapeutic exercises, neuromuscular reeducation, gait training, group procedures, therapeutic activities, and wheelchair management training. Documentation shows the resident received only two PT sessions on consecutive days, with no further PT provided before the resident was discharged to the hospital. In interviews, the Director of Rehab stated there was a gap in PT staffing, that the facility did not have a full-time PT, and that she could not get a PT to come in, contributing to the delay and limited provision of PT services for this resident.
Failure to Consistently Post and Maintain Required Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post accurate daily nurse staffing information as required. On one survey date at 8:45 AM, the surveyor observed that no Staffing Data Daily posting was present at the front desk or anywhere in the facility. Later that day, the Nursing Home Administrator (NHA) stated there was no posting for that date because the Scheduler was not present. When the surveyor requested the last 30 days of Staffing Data Daily postings, the NHA later acknowledged that these postings could not be provided because the Scheduler did not retain them and shredded them daily, leaving no evidence of prior postings for comparison with staffing schedules. On a subsequent day, the surveyor observed that a Staffing Data Daily posting was present at the entrance front desk and on a hallway bulletin board, listing the date, census, and numbers of LPNs, RNs, CNAs, and an on-call DON for each shift. However, this posting did not include the facility name, staff per unit, shift times, or actual hours worked and/or total FTEs. During an interview, the Human Resources Assistant, who also functions as Scheduler, described typical shift times, minimum staffing requirements for each unit and shift, and the process for posting staffing data around 6:30 AM, including making written changes for census changes or call-ins. The Scheduler confirmed that postings are placed by the time clock, hallway bulletin board, front desk, and vent unit, and verified that postings were in those locations. The Scheduler also stated that postings are shredded daily and not kept, and that the NHA covers staffing postings when the Scheduler is absent, though the Scheduler had not yet taken vacation. On another survey date at 8:07 AM, the surveyor observed that the Staffing Data Daily postings at the hallway, front desk, and time clock were all dated several days earlier and that there had been no postings over the intervening weekend. The outdated posting also lacked the facility name, total hours worked, or FTEs per shift. At 8:44 AM that same day, there was still no updated posting for the current date, and the outdated posting remained in all locations. By 9:11 AM, an updated posting for the current date was observed, but it again did not include the facility name, total hours worked per shift, or FTEs per shift. In interviews, the Scheduler did not know who was responsible for weekend postings, and the NHA confirmed there were no policies or procedures for Staffing Data Daily postings, incorrectly identified the required components of the posting, and acknowledged that no one was currently responsible for weekend postings. The surveyor noted the absence of postings on specific dates and the lack of any record of staffing data postings for the past 18 months.
Failure to Provide Wound Care and Neurological Assessments per Policy
Penalty
Summary
The facility failed to ensure that a resident with diabetes received daily foot checks as required by the care plan and facility policy. Despite the care plan specifying daily inspections for open areas, sores, pressure areas, blisters, edema, or redness, there was no documentation in the Treatment Administration Record (TAR) or CNA Kardex that these checks were being completed. Interviews with nursing staff and the Director of Nursing (DON) revealed confusion regarding the frequency of foot checks, with some staff believing they should be performed weekly rather than daily. Additionally, there was no physician order for daily foot checks, and the facility did not provide evidence that the checks were performed as required. The same resident developed a right heel wound, which the wound physician identified as a diabetic wound, while facility staff documented it as an unstageable pressure injury. The wound physician ordered a specific treatment for the wound, but this order was not entered into the resident's electronic medical record, and there was no documentation that the treatment was implemented or that wound care was provided after the initial assessment. Furthermore, the facility failed to conduct and document weekly wound assessments and measurements as required by policy, particularly when the resident was absent from the facility during scheduled wound rounds due to dialysis appointments. Despite a plan for the wound nurse or DON to assess the wound if the wound physician was unavailable, no such assessments were documented after the wound's initial identification. In a separate incident, another resident who experienced multiple unwitnessed falls did not receive thorough and complete neurological checks as required by facility policy. The neurological flow sheets for these incidents contained multiple missing entries for key assessment parameters such as level of consciousness, speech, pupil reaction, and hand grasps. The facility's policy outlined a specific schedule and required documentation for neurological assessments following unwitnessed falls, but these were not consistently followed or recorded. Interviews with the DON confirmed the expectation that neurological assessments should be completed after each unwitnessed fall, yet the documentation provided was incomplete.
Failure to Obtain Physician Order and Update Care Plan for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident who had a tracheotomy tube removed was subsequently placed on supplemental oxygen via nasal cannula without a physician's order specifying the oxygen administration details. The facility's policy requires a physician's order for oxygen administration, including specifics such as flow rate, delivery method, and parameters for use. However, after the resident's decannulation, no new order was obtained for the oxygen therapy provided, and the care plan was not updated to reflect the change in respiratory support. The resident had a complex medical history, including acute and chronic respiratory failure, COPD, asthma, and a tracheostomy. Documentation showed that the resident was receiving 3 liters of oxygen via nasal cannula following the removal of the tracheostomy tube, but there was no corresponding physician order or individualized care plan update specifying the method, amount, or frequency of oxygen delivery. Progress notes and staff interviews confirmed that oxygen was administered and documented, but the required medical order and care plan details were missing during the resident's stay after decannulation. Interviews with nursing staff, including LPNs, RNs, and the DON, revealed a consensus that a physician's order is necessary for oxygen administration and that the care plan should include specific details about oxygen therapy. Despite this, the facility failed to obtain the required order and did not update the care plan to reflect the resident's new oxygen needs, resulting in a lack of compliance with facility policy and regulatory requirements.
Systemic Failure to Assess and Address Hydration Needs Leads to ICU Admission
Penalty
Summary
A facility failed to adequately assess and address the hydration status of a resident with multiple complex medical conditions, including bladder cancer, dysphagia, dementia, schizophrenia, and major depressive disorder. The resident required a mechanically altered diet and substantial assistance with eating. Despite being identified as at risk for compromised nutrition and hydration, the care plan interventions focused primarily on nutrition and weight loss, with insufficient attention to hydration needs. The resident's fluid intake was consistently below recommended levels, with documented daily averages significantly lower than the fluid goal previously established in a dietary assessment. There was no updated or current fluid intake goal documented in the resident's medical record for an extended period. Laboratory results repeatedly showed elevated sodium, BUN, and chloride levels, indicating dehydration, yet no new interventions or orders were implemented in response to these findings. The nurse practitioner documented concerns about dehydration and recommended encouraging hydration and repeating laboratory tests, but did not enter specific orders into the system. Communication between the nurse practitioner, dietary, and nursing staff was inadequate, resulting in a lack of clear direction and follow-up on hydration interventions. The dietary department was not informed of the resident's dehydration risk or abnormal lab results, and fluid intake documentation was not reviewed by the interdisciplinary team or nursing staff. The resident's condition deteriorated, with increased confusion, lethargy, and visible signs of dehydration, ultimately leading to hospitalization in the ICU for hypernatremia, acute kidney injury, and a urinary tract infection. Interviews with facility staff and providers revealed that the focus remained on nutrition and weight loss rather than hydration, and that communication breakdowns prevented timely and appropriate interventions. The systemic failure to monitor, assess, and intervene for the resident's hydration needs resulted in a serious adverse outcome.
Removal Plan
- Educate all facility nursing staff on fluid intake documentation, monitoring, change of condition, hydration assessments and when to update provider.
- Educate Nurse Practitioner on monitoring change of condition, making clear orders to nursing staff, and communication process with nursing staff.
- Educate Dietician on implementation of fluid intake goals, clear communication with nursing staff, and monitoring for residents at risk for dehydration.
- Require nurses/CNAs to complete competency before being scheduled.
- Conduct competencies and education by nursing management and/or a nurse who has passed the competency education and has been designated to give education.
- Review and update plan of care for all residents at risk for dehydration. Monitoring includes tracking system in Point Click Care, dietician meetings, nurse manager/DON audit oversight, review of charting and fluid intake for at risk residents in stand up.
- Review and update policy and procedure for hydration to include: The dietician or consulting dietician will work together with staff to identify residents at risk for fluid deficit or with specific fluid intake needs. The dietician will determine the optimal fluid intake amount for residents at risk and will communicate that to the nursing staff with a breakdown of recommended fluid amounts per shift, per meal, per med pass, and/or water pass. The dietician and staff will monitor for the subsequent development, progression and/or resolution of fluid deficit or fluid restrictions in all at-risk individuals to ensure appropriate interventions and/or follow up continues. The dietician will participate in Nutritional at Risk meetings and maintain on-going dialogue.
Lack of Effective Staff Training Program and Documentation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, including contracted staff, as required by facility policy and federal regulations. During a survey, it was found that eight facility staff and one contracted employee did not have documentation of completing the required orientation and annual in-service training. The staff members affected included dietary, housekeeping, nursing, and certified nursing assistants, as well as a contracted registered dietitian. The facility's own policies require all staff, including contracted personnel, to participate in initial and annual training covering topics such as resident rights, abuse prevention, infection control, and compliance, with documentation maintained for each training session. Upon review of employee records, the surveyor was unable to find evidence that the selected staff had completed the required education and training within the year based on their hire dates. Interviews with the Nursing Home Administrator (NHA), Director of Employee Services (DES), and Director of Nursing (DON) revealed a lack of a formal system for tracking and maintaining records of staff training. The DON acknowledged that there was no specific education or training coordinator in place and that the facility did not have a process to ensure all required trainings were completed and documented for both facility and contracted staff. Further, the DON was unaware that contracted employees, such as the registered dietitian, were also required to complete the facility's educational trainings. The DES and DON provided conflicting accounts regarding responsibility for tracking and filing training documentation, and it was confirmed that the facility did not have a process in place for maintaining records of staff receiving required trainings at the time of the survey. No additional information was provided to explain why the required trainings were not completed or documented for the affected staff.
Failure to Provide and Document Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that six randomly selected direct care staff members and one contracted employee received the required effective communication training as outlined in the facility's in-service training policy. The policy mandates that all staff, including new hires, existing personnel, contracted individuals, and volunteers, participate in regular in-service education, with effective communication as a required topic. During the survey, the facility was unable to provide documentation that the selected staff, including a registered nurse, a registered dietitian, and several certified nursing assistants, had received this training within the required timeframe based on their hire or contract dates. Interviews with facility leadership revealed a lack of a systematic process for tracking and documenting staff training. The Director of Employee Services stated that their role was limited to filing completed training documents, while the Director of Nursing acknowledged there was no system in place to monitor educational training completion. Additionally, there was confusion regarding the responsibility for ensuring contracted employees received the required training. The absence of documentation and a clear tracking system resulted in the deficiency, with no evidence that the required effective communication training was provided to the identified staff.
Failure to Provide Required Abuse Prevention and Dementia Training to Staff
Penalty
Summary
The facility failed to ensure that 8 out of 8 randomly selected staff members, as well as one contracted employee, received required training on abuse prevention, activities that constitute abuse, procedures for reporting abuse, and dementia management. Review of employee records for a dietary aide, housekeeper, registered nurse, registered dietitian, and several certified nursing assistants revealed no documentation of these trainings within the required timeframe based on their hire dates. The only available documentation was a quiz on elder abuse in the community, which did not meet the requirements for facility-specific abuse prevention and reporting training. Interviews with facility leadership, including the Nursing Home Administrator (NHA), Director of Employee Services (DES), and Director of Nursing (DON), confirmed that there was no effective system in place to track or ensure completion of required educational trainings for employees. The DON acknowledged being unaware that contracted employees, such as the registered dietitian, were also required to receive these trainings. The DES and DON provided conflicting accounts regarding responsibility for maintaining and tracking training records, and it was confirmed that many training documents may not have been filed or completed as required. The facility's own policy mandates that all staff, including contracted personnel, participate in initial orientation and annual in-service training on topics such as abuse prevention, reporting procedures, and dementia management. The lack of documentation and absence of a tracking system resulted in the facility being unable to demonstrate compliance with these requirements for the selected staff, potentially affecting all 59 residents in the facility.
Failure to Provide Required QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff, including contracted employees, received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program as required by facility policy. Eight randomly selected staff members, including a dietary aide, housekeeper, registered nurse, five certified nursing assistants, and a contracted registered dietitian, did not have documentation of having received QAPI training within the required timeframe. The facility's policy mandates that all staff, including those under contract, participate in initial orientation and annual in-service training covering QAPI elements and goals, among other topics. However, upon review of employee records, the surveyor found no evidence that these individuals had completed the required QAPI training. Interviews with facility leadership revealed a lack of a systematic process for tracking and documenting staff training. The Director of Employee Services (DES) and Director of Nursing (DON) provided conflicting accounts regarding responsibility for maintaining training records, with the DON acknowledging the absence of a tracking system and being unaware that contracted employees were also required to complete the training. The surveyor confirmed that the facility could not provide documentation to show that the identified staff had received the necessary QAPI training, as required by policy.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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