Aria At Villa Pines
Inspection history, citations, penalties and survey trends for this long-term care facility in Friendship, Wisconsin.
- Location
- 201 Park St., Friendship, Wisconsin 53934
- CMS Provider Number
- 525351
- Inspections on file
- 18
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Aria At Villa Pines during CMS and state inspections, most recent first.
Surveyors found multiple sanitation failures in the kitchen, including a stove hood with accumulated dust on filters, sprinklers, light fixtures, shelving, and a metal box directly over the food prep area, which staff acknowledged had not been properly cleaned by Maintenance. A dented can was observed in active dry storage, despite staff stating such cans should be removed and returned to the supplier. In addition, a stand mixer stored under plastic covering was found to have hardened food particles on its undercarriage, contrary to facility policy requiring small appliances to be cleaned and sanitized after each use.
The facility failed to maintain an effective infection prevention and control program by omitting 11 COVID-positive residents from the January infection control record, despite policies requiring complete outbreak tracking logs and accurate monthly infection rate analysis. Additionally, a CNA was observed performing pericare and indwelling catheter care for a resident, then, without removing gloves or performing hand hygiene, adjusting the resident’s bedding, repositioning the catheter drainage bag, and assisting with clean undergarments, contrary to facility policies on standard precautions, perineal care, and catheter care. The DON and CNA both acknowledged that pericare/catheter care is a dirty task and that gloves are contaminated afterward, requiring hand hygiene and glove changes before handling clean items.
The deficiency concerns the facility’s failure to consistently notify a physician of significant daily weight changes for a resident with pulmonary hypertension, acute respiratory failure with hypercapnia, and stage 3 CKD who was on a loop diuretic and ordered for daily weights with MD notification for changes over 3 lbs in a day or 5 lbs in a week. Medication and weight records showed multiple instances of weight gains and losses exceeding 3 lbs in a 24‑hour period without documented physician notification, even though staff used a secure messaging app to communicate changes and acknowledged that only some weight issues were reported. Review of the messaging history and records confirmed that on several days with qualifying weight fluctuations, no MD notification occurred, contrary to the physician’s order and the facility’s change‑of‑condition policy.
A resident with multiple chronic conditions, cognitive communication deficits, and impaired decision-making requested a suppository for constipation. During the procedure, the resident screamed for staff to stop, stating the staff member was elbowing them. Facility policy requires immediate reporting of all alleged abuse, neglect, exploitation, or mistreatment to the administrator and State Survey Agency, and the DON acknowledged such an event should be reported, especially when a nurse is involved. The NHA stated they were present, spoke with staff and the resident, but there was no documentation of interviews and no report was submitted to the State Agency, resulting in a failure to report a potential abuse allegation as required.
A resident with COPD, chronic heart failure, muscle wasting, weakness, cognitive communication deficit, and moderate decision-making impairment cried out "stop, stop you are elbowing me" while an RN and CNA were repositioning the resident and inserting a suppository for constipation. Facility policy requires that all abuse allegations be investigated, including interviews with the reporter, anyone with direct knowledge, the resident if possible, and other residents and staff who regularly receive care from or work with the accused. Although the RN reported the concern to the DON and the NHA spoke with the involved CNA and the resident, no interviews were conducted with other residents or staff, and there was no documentation of interviews or a complete investigation, resulting in a failure to follow the facility’s Abuse Prevention Program.
A resident with dementia, anxiety, depression, and severe cognitive impairment was assessed as at risk for elopement, with a plan for a WanderGuard device and a physician order to check its function and placement every shift. Facility policy required at-risk residents to have elopement precautions such as a WanderGuard, with regular testing and documentation. Although the resident was observed wearing a WanderGuard, review of the Treatment Administration Record showed a gap of several months with no WanderGuard check order or documentation. An RN and the DON both stated that WanderGuard checks should be documented in the TAR every shift but were unable to locate any such documentation for this resident, and the DON acknowledged entering the physician order with an incorrect future start date, resulting in the lack of ongoing monitoring records.
A resident with CHF, interstitial lung disease, and chronic respiratory failure was receiving O2 via nasal cannula with humidification at 3 LPM. Facility policy required routine changes of oxygen delivery devices, and the MD order specified weekly changes of oxygen tubing and related supplies with staff to initial and date them. During observation, the surveyor noted the tubing tag showed a change date several weeks earlier, and a CNA confirmed this date despite stating tubing is changed weekly. The DON later acknowledged that the tubing should be changed weekly and that the facility missed changing this resident’s oxygen tubing as ordered.
A resident receiving hospice services for chronic pain and post-stroke hemiplegia/hemiparesis had PRN morphine sulfate oral solution (20 mg/mL) with a documented expiration date that remained in the medication cart and was administered after it had expired. Facility policy required nurses to check expiration dates before administration and to remove and destroy all expired medications, but the expired morphine remained on the cart with multiple prefilled syringes and was given on several documented occasions. The expiration date was also recorded in the narcotic count binder, yet staff did not remove or discard the medication as required.
Surveyors found that the facility exceeded the acceptable medication error rate when a med tech crushed two different extended-release (ER) medications and administered them in applesauce to two residents, despite facility policy prohibiting crushing long-acting or enteric-coated drugs. One resident received Isosorbide Mononitrate ER for essential HTN in crushed form, and another received Metoprolol Succinate ER for ventricular rate control in A-fib in crushed form. The med tech later acknowledged knowing ER medications should not be crushed, and the DON confirmed that staff are expected not to crush ER medications.
A resident with chronic pain and other medical conditions reported concerns about a nurse administering unfamiliar medication and not following her preferences for medication delivery. The facility's investigation lacked documentation of staff interviews and did not provide the resident with written follow-up or obtain her signature on the grievance resolution, as required by policy. Leadership confirmed that Tylenol was offered instead of the prescribed hydrocodone-acetaminophen, despite no order for Tylenol, and no further staff or resident interviews were conducted.
Two residents reported receiving cold food, and a test tray confirmed that hot foods were served below required temperatures and cold foods above safe limits. The issue was attributed to delays in the tray line, partly due to a new staff member in training, resulting in unpalatable and improperly held food.
Unsanitary Kitchen Hood, Equipment, and Food Storage Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, with the potential to affect all 33 residents. During an observation of the kitchen, the surveyor and the Dietary Manager noted that the stove hood above the food preparation area had visible dust on the filter, sprinklers, light fixtures, a metal box, and a 5-foot shelf. The Dietary Manager acknowledged that the hood needed cleaning, that Maintenance was responsible for this task, and that there was potential for dust to dislodge and fall into food being prepared underneath. A subsequent observation with another staff member showed that the metal box on the hood remained covered with dust, and this staff member confirmed that the Maintenance worker was supposed to clean it but had missed that section, again acknowledging the potential for dust to fall into food. Additional unsanitary conditions were identified in food storage and equipment cleaning. In the dry storage area, the surveyor observed a dented can on the shelf in circulation, and the Dietary Manager stated that such cans should be removed and returned to the supplier for credit. The facility’s policy on food preparation appliances required that small appliances such as mixers be cleaned and sanitized after each use. However, when the surveyor asked the Dietary Manager to remove the plastic covering from the stand mixer that was reported to be clean, hardened food particles were observed on the undercarriage. The Dietary Manager acknowledged that the mixer had not been thoroughly cleaned before being stored, contrary to facility policy.
Failure to Maintain Accurate Infection Surveillance and Adhere to Standard Precautions During Catheter and Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program as required by its own policies. During a COVID-19 outbreak, the facility’s January 2026 resident line list showed 11 residents with COVID-19, but the January 2026 monthly infection control record only documented 3 residents with lower respiratory infections and did not include the 11 COVID-positive residents. Facility policies on management of COVID-19, influenza, and other acute respiratory infection outbreaks, as well as infection surveillance, required the Infection Preventionist or designee to initiate tracking logs/line lists, complete all sections of the log, and complete the monthly rate and analysis for the month. The DON/IP confirmed that all infections, including COVID-19, should be included on the monthly infection control record and acknowledged that omitting the 11 residents meant the January infection control rates would not be accurate. The deficiency also includes a breach in infection control practices during direct resident care. A CNA was observed performing perineal care and indwelling catheter care for a resident after donning a gown and gloves, cleansing, rinsing, and drying the perineal area and catheter tubing. Without removing gloves or performing hand hygiene, the CNA then adjusted the resident’s bedding, repositioned the catheter drainage bag, and assisted the resident with application of clean undergarments. This practice conflicted with the facility’s policies on standard and transmission-based precautions, perineal care, and indwelling catheter care, which require glove removal and hand hygiene when moving from dirty to clean tasks. In interviews, both the CNA and the DON acknowledged that pericare/catheter care is considered a dirty task, that gloves are contaminated afterward, and that hand hygiene and glove changes are required before touching clean bedding and clothing.
Failure to Notify Physician of Significant Daily Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify and consult with a resident’s physician when there was a change in condition, specifically significant daily weight fluctuations, as required by physician orders and facility policy. The facility’s “Change of Condition Process” policy states that when a change from baseline is observed, such as weight loss or gain, the licensed nurse must evaluate the resident and notify the physician. One resident, admitted with pulmonary hypertension, acute respiratory failure with hypercapnia, and stage 3 chronic kidney disease, had an order for daily weights with instructions to call the MD if there was a 3‑pound change overnight or a 5‑pound change in a week. Medication records showed multiple instances of weight changes greater than three pounds in a single day, including losses and gains of 3.5 to 7.9 pounds, without corresponding physician notification. Surveyor interviews and record reviews confirmed that the facility used a secure messaging app (Hucu) to notify physicians of changes, and that some general notifications about weight were sent on certain dates. However, there was no documentation that the physician was notified on specific dates when the resident’s weight changed by more than three pounds in one day, despite the standing order to do so. Staff, including an RN, the DON, and the ADON, acknowledged that notifications were sent only on some occasions and that factors such as timing of weights and resident refusals might affect whether a physician was contacted. Review of the Hucu message history and other documentation showed gaps in physician notification on multiple dates with qualifying weight changes, demonstrating that the physician order and facility policy for change‑in‑condition notification were not consistently followed.
Failure to Report Alleged Abuse Incident to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged incident of potential abuse to the administrator and the State Survey Agency as required by its Abuse Prevention Program and state/federal regulations. The facility’s policy states that it prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment, and that it will prevent such occurrences in part by filing accurate and timely investigative reports. One resident, admitted with multiple chronic conditions including COPD, chronic combined systolic and diastolic heart failure, muscle wasting and atrophy, weakness, a cognitive communication deficit, and a need for assistance with personal care, was documented as rarely/never understood and unable to complete the BIMS, with moderately impaired decision-making. This resident requested a suppository for constipation, and during the procedure, while being repositioned on the left side and having the suppository inserted, the resident screamed loudly, “stop, stop you are elbowing me.” The Director of Nursing stated that in a situation where a resident says, “Stop, stop you’re elbowing me,” staff should stop, apologize, get another person to assist, and report to the nurse, and further acknowledged that if a nurse is involved, the incident should be reported. Review of the resident’s progress note documenting the event showed no evidence that the incident was treated as a reportable allegation. The DON did not recall the situation but stated she felt she would have followed up and updated the Nursing Home Administrator to start an investigation. The Nursing Home Administrator reported being present at the time of the incident and speaking with both staff and the resident, but confirmed there was no documentation of interviews and that the incident was not reported to the State Agency. As a result, the facility did not submit a required report to the State Agency for this potential allegation of abuse.
Failure to Thoroughly Investigate Allegation of Abuse During Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of abuse involving one resident. The facility’s Abuse Prevention Program requires that all incidents or allegations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property result in an investigation, including interviews with the person who reported the incident, anyone likely to have direct knowledge, the resident if interviewable, and other residents and employees with whom the accused regularly works. Despite this policy, when an allegation arose that a resident was being elbowed during care, the facility did not follow all required investigative steps, including interviewing other residents and staff who might have relevant information. The resident involved had multiple medical conditions, including COPD, chronic combined systolic and diastolic heart failure, muscle wasting and atrophy, weakness, a cognitive communication deficit, and a need for assistance with personal care. A progress note documented that the resident was rarely or never understood, had memory problems, and was moderately impaired in decision-making, though could identify the current season and recognize being in a nursing home or hospital. On the day of the incident, a nurse and a CNA repositioned the resident on the left side to insert a suppository for constipation, and during the procedure the resident screamed loudly, “stop, stop you are elbowing me.” Staff interviews confirmed awareness that when a resident says “stop,” staff are expected to stop and ensure safety, and that such an event involving a nurse should be reported and investigated. The RN involved stated that the resident called out frequently and that the family had a camera in the room and might think abuse was occurring, and reported being certain the DON was informed because it could sound abusive. The NHA recalled being told that the resident said staff were elbowing them, spoke with the CNA and the resident, and was told there was no elbowing and nothing was wrong. However, the NHA acknowledged that no interviews were conducted with other residents under the care of the involved staff, no documentation of interviews with the RN, CNA, or resident existed, and there was no complete investigation of the incident as required by the facility’s Abuse Prevention Program.
Failure to Ensure WanderGuard Monitoring and Documentation for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate elopement prevention interventions and documentation for a resident assessed as at risk for elopement. The facility’s Elopement Prevention and Missing Resident Policy required that residents at risk for elopement be provided with safety precautions such as a WanderGuard device, with all devices tested and documented as part of the preventive maintenance program. The resident, admitted with dementia, anxiety disorder, and depression, had a Minimum Data Set showing a BIMS score of 3, indicating severe cognitive impairment. An elopement risk assessment concluded the resident was at risk for elopement, with a plan for a WanderGuard to be in place. A physician order directed staff to check the WanderGuard’s function and placement every shift, but the start date was incorrectly entered as a future year. Record review of the Treatment Administration Record (TAR) showed that from admission through a specified date, the WanderGuard checks were ordered and documented, but from that date until several months later there was no order in the TAR for checking the WanderGuard. During observation, the resident was seen wearing a WanderGuard on the left wrist. In interviews, an RN described the process for WanderGuard use, including activation, awareness of expiration dates, and documenting checks each shift in the TAR, and confirmed that documentation should be in the TAR. However, the RN was unable to locate any WanderGuard documentation for this resident in the TAR. The DON similarly stated that WanderGuard documentation should be in the TAR every shift but could not find any such documentation for the resident and acknowledged that the physician order had been entered with the wrong start year. This combination of an incorrect order start date and lack of TAR documentation demonstrated that the facility did not ensure the resident’s WanderGuard was checked and documented each shift as required by policy and physician order.
Failure to Change Oxygen Tubing per Physician Order and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and physician orders for a resident receiving oxygen therapy. The facility’s policy on oxygen tubing changes states that oxygen delivery devices, including tubing and cannulas, are to be changed routinely, with tubing changed every 14 days when humidification is in use. The resident had physician orders specifying that oxygen tubing and supplies, including cannula, tubing, humidifier bottles, and concentrator filter washing, were to be changed weekly on Fridays, with staff to initial and date the supplies. The resident was admitted with diagnoses including acute on chronic diastolic congestive heart failure, interstitial pulmonary disease, and chronic respiratory failure, and was receiving oxygen via nasal cannula from a concentrator with humidification at 3 LPM. During observation, the surveyor noted that the resident’s oxygen tubing had a green tag labeled with a change date of 3/31, indicating it had not been changed as ordered by the time of the surveyor’s visit on 4/20. When interviewed, a CNA stated that oxygen tubing is changed weekly and, upon checking the label on the resident’s tubing, confirmed the date of 3/31. In a subsequent interview, the DON stated that oxygen tubing needs to be changed weekly and acknowledged that the facility had missed changing the tubing for this resident. This sequence of observations and interviews shows that the resident’s oxygen tubing was not changed according to the weekly physician order or the facility’s stated practice.
Expired Morphine Sulfate Administered and Stored on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services were provided in accordance with its own medication storage policy, resulting in the administration and continued availability of expired morphine sulfate oral solution for a resident. The facility’s policy required that outdated medications be immediately removed from inventory, that nurses check expiration dates before administration, and that no expired medications be administered. Despite this, a morphine sulfate oral solution (20 mg/mL) prescribed as needed for dyspnea and moderate to severe pain for a resident with hemiplegia, hemiparesis following cerebral infarction, and chronic pain remained in the medication cart after its printed expiration date of 12/28/25. During a medication cart observation, an RN and the surveyor identified that five prefilled syringes of this medication with the expired date were still present in the cart, and the RN expressed surprise that they remained there. Record review showed that the expired morphine sulfate oral solution was administered to the resident on multiple occasions after the expiration date. The MAR documented administrations on specific dates in February and April, confirming that nursing staff had given the expired medication despite the policy requirement to verify expiration dates before each administration and to discard expired medications. The expiration date was also documented in the narcotic count binder, indicating that the information was available but not acted upon. During interview, the DON stated that medication carts should be checked frequently for expired medications and acknowledged the expectation that the morphine sulfate should have been discarded and not used past its expiration date.
Crushing of Extended-Release Medications Resulting in Elevated Med Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 25 opportunities, resulting in an 8% error rate. Facility policy titled "Medication Administration-General Guidelines" dated December 2019 states that long-acting or enteric-coated dosage forms should not be crushed and that an alternative should be sought. Despite this policy, on 4/21/26 at 7:31 AM, a medication technician (MT H) was observed administering two tablets of Isosorbide Mononitrate ER 30 mg, ordered as a total of 60 mg once daily for essential hypertension, crushed in applesauce to Resident 21. The physician’s order and the MAR both specified Isosorbide Mononitrate ER 24-hour extended-release tablets, but they were not administered intact as ordered. In a second example, Resident 15 had a physician’s order and corresponding MAR entry for Metoprolol Succinate ER 24-hour 25 mg, with instructions to give 0.5 tablet by mouth once daily for ventricular rate control in atrial fibrillation. On 4/21/26 at 7:50 AM, MT H was observed crushing the Metoprolol Succinate ER tablet and administering it in applesauce, contrary to the extended-release instructions. During an interview on 4/22/26 at 7:23 AM, MT H acknowledged knowing that extended-release medications should not be crushed and admitted to crushing both the Isosorbide ER and Metoprolol ER during the observed med pass. In a separate interview at 10:00 AM, the DON confirmed that extended-release medications should not be crushed and stated an expectation that staff would not crush such medications.
Failure to Promptly Investigate and Resolve Resident Grievance Regarding Medication Administration
Penalty
Summary
A resident with a history of left pubic fracture, type 2 diabetes mellitus, major depressive disorder, and chronic pain, who was cognitively intact, reported a grievance regarding medication administration. The resident expressed concerns that a nurse attempted to administer medications in a manner she was uncomfortable with and that one of the medications appeared unfamiliar. Upon questioning, the nurse took the medications back to the med cart and returned with the correct ones. The resident reported this incident to the Social Services Director (SSD), who initiated a grievance process. The facility's grievance policy requires that grievances be routed to the appropriate department head, investigated thoroughly, and that the resident be provided with a verbal follow-up including details of the investigation and its resolution. However, the investigation into the resident's grievance lacked documentation of interviews with staff or other residents, aside from the SSD's interview with the complainant. There was also no written communication of the grievance resolution provided to the resident, and the facility did not obtain a signature from the resident or representative indicating agreement or disagreement with the outcome. Interviews with facility leadership revealed that the nurse attempted to administer Tylenol instead of the resident's scheduled hydrocodone-acetaminophen due to the unavailability of the prescribed medication, despite the resident not having an order for Tylenol. The facility did not conduct interviews with other staff or residents regarding the incident, and there was no comprehensive documentation of the investigation or follow-up with the resident as required by policy.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
Surveyors identified that the facility failed to ensure food and drink were served at palatable and safe temperatures for two of seven sampled residents. An anonymous complaint was received regarding food temperatures, and both residents interviewed expressed concerns about receiving cold food. During observation, a test tray was requested after all residents on the 200 wing had been served lunch. The test tray revealed that the Chicken Tetrazzini was served at 128.7°F, the cauliflower/broccoli at 130.5°F, and the milk at 50.5°F, all of which were outside the facility's policy requirements for safe food temperatures. Additionally, the cauliflower/broccoli was noted to be mushy and not palatable. Interviews with the residents confirmed ongoing issues with food temperature, with one resident stating that her eggs were often cold and another stating that the food was not always hot enough. The Dietary Manager acknowledged that the tray line was running late due to a new staff member in training, which may have contributed to the delay and subsequent drop in food temperatures. The Dietary Manager also confirmed that the temperatures recorded by the surveyor were below the required standards and that the food was not palatable due to temperature and texture issues.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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