Ascension Living - Lakeshore At Siena
Inspection history, citations, penalties and survey trends for this long-term care facility in Racine, Wisconsin.
- Location
- 5643 Erie Street, Racine, Wisconsin 53402
- CMS Provider Number
- 525495
- Inspections on file
- 28
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Ascension Living - Lakeshore At Siena during CMS and state inspections, most recent first.
Failure to Assess, Treat, and Prevent Pressure Injuries: Multiple residents with pressure injuries or high skin-breakdown risk did not receive consistent wound assessments, ordered treatments, heel offloading, or timely care plan revisions. A resident with a sacral wound had repeated reopening and new ischial wounds without a documented root cause, while another resident developed a heel blister that progressed to an unstageable injury and then a stage 3 pressure injury with delayed assessment and incomplete TAR documentation. Other residents had worsening heel, buttock, and sacral wounds without timely comprehensive assessments or individualized prevention measures.
Surveyors found that the facility failed to thoroughly assess multiple resident falls and did not promptly individualize fall-prevention care plans. Cognitively intact residents with conditions such as diabetes, COPD, stroke, orthostatic hypotension, and Alzheimer’s had unwitnessed and witnessed falls during toileting, in bed, and during transfers, including events that resulted in fractures and hospital transfers. Post-fall documentation often lacked root cause analysis, omitted key details (such as incontinence, footwear, or environmental factors), and left intervention sections blank. Therapy recommendations for transfer assistance were not timely incorporated into ADL care plans, leading to staff confusion and use of incorrect transfer methods. CNA worksheets, derived from non-individualized care plans, listed multiple or conflicting transfer instructions, and staff interviews showed uncertainty about who was responsible for updating care plans after falls.
Failure to Reassess Dementia Behaviors and Aggression A resident with severe cognitive impairment and dementia had repeated wandering, room-entry, yelling, and combative behaviors, including aggression toward staff and another resident. The care plan included redirection and supervision interventions, but the record did not show a formal behavior tracking system or a comprehensive reassessment of interventions despite ongoing incidents. A resident-to-resident altercation in which the resident grabbed another resident’s forearm caused pain and fear, yet the event was not documented in the resident’s chart, and psych services were not obtained until later.
Failure to Maintain Required BID Screening: The facility did not ensure a BID was completed every four years for the DFM, whose file contained an older BID but no current one within the required timeframe. Survey review of employee records found the missing BID, and the NHA stated HR was not aware the BID had to be completed every four years.
Resident medical records were not safeguarded against loss, destruction, or unauthorized use. Surveyors observed multiple boxes of resident records sitting directly on the floor and several boxes uncovered in a basement storage room that also contained DME and maintenance items such as wheelchair parts and mattresses. The NHA and MRA confirmed older and previous resident records were stored there, and access to the room was not clearly limited.
QAPI Program Failed to Identify Systemic Deficiencies: The facility’s QAPI/QAA process did not identify or correct systemic issues before survey, despite 27 deficiencies being cited, including actual harm at F686, F689, and F744 and substandard quality of care at F606 and F686. Surveyors found widespread deficient practice involving QAPI, QAA, infection prevention, antibiotic stewardship, a designated IP, and QAPI training, while the QAPI plan did not address infection control, dementia care, or late med administration. The NHA stated the facility was still working on PIPs for falls and wounds, was planning a paper behavior log, and did not have one designated IP at QAPI meetings.
QAPI committee membership was not maintained as required because the DON did not sign in to 4 of 10 reviewed QAPI meetings. Survey review of attendance records and meeting minutes showed that monthly QAPI meetings were held, but the DON was absent from several meetings despite the NHA stating the DON was part of the regular attendee group along with the Medical Director, MDS coordinator, social services, NHA, and other departments.
The facility did not maintain an effective IPCP, with no ongoing infection surveillance documentation and no documentation of investigation or preventive actions for two COVID outbreaks. Staff gave inconsistent answers about isolation and EBP, and surveyors observed PPE and precaution failures for residents with MRSA, catheters, wounds, and a PICC line. A resident with MRSA was not properly identified for contact precautions, another resident’s catheter bag was left on the floor, and an LPN/CNA did not follow hand hygiene and glove changes during care.
The facility did not establish an antibiotic stewardship program with antibiotic use protocols or a system to monitor antibiotic use. Survey review found no documentation of antibiotics administered in the facility, including indications, duration, organism, isolation, or infection criteria. The NHA and DON stated the QD was in training and that infection surveillance documents were still being compiled, and the facility did not have a designated, qualified IP.
No designated, qualified IP was responsible for the facility’s IPCP. The NHA and DON were overseeing the program while the QD was still in training and had not fully started in the role. The facility assessment did not document an IP, and the report states there was no additional explanation for why a designated infection preventionist was not in place.
Mandatory QAPI training was not documented for 2 of 5 direct care staff reviewed, including two CNAs who lacked evidence of annual QAPI education. Survey review found the facility’s training records did not show the required QAPI training, despite a policy requiring ongoing and annual training for all staff and participation in QAPI-related education.
Multiple residents were not comprehensively assessed or treated according to professional standards and facility protocols. One resident with antibiotic-associated diarrhea developed macerated skin on the buttocks that was not fully assessed or reported to a provider, while an antifungal powder from a prior hospitalization was applied without an order and by a CNA. Another resident admitted with right leg cellulitis and multiple diabetic and non-pressure ulcers had no descriptive documentation of the cellulitis, and an order to cleanse and apply betadine did not specify the treatment site. A resident on Xarelto had an unwitnessed fall from bed onto an overbed table, with abrasions, hypotension, and altered mental status; staff moved the resident with a mechanical lift and called a private ambulance instead of 911, and the NP was not given vital signs. A hospice resident with an unwitnessed fall and severe back pain did not receive neurological checks at the frequencies required by the facility’s neuro assessment protocol. Another resident with a new skin wound did not receive a comprehensive wound assessment or the ordered wound consult, and after an unwitnessed fall while on blood thinners, did not receive a thorough post-fall neurological assessment.
A facility failed to administer medications timely and as ordered for multiple residents, including one with severe cognitive impairment and generalized anxiety disorder whose scheduled hydroxyzine was repeatedly given outside the facility’s 1-hour administration window, was unintentionally discontinued for two days, and later continued to be administered late or omitted after being restarted. Other residents received morning medications, including statins, antidepressants, analgesics, and anticoagulants, more than two hours after scheduled times, and one resident’s IV cefepime regimen for a catheter-associated UTI included missed initial doses due to pharmacy delay, a dose given over five hours early, and several doses not signed out at all. Staff interviews revealed uncertainty about who reviews provider assessments and uploads them into charts, and nurses reported workload issues and documentation gaps despite a facility policy requiring medications to be given within 60 minutes before or after the ordered time.
Care plans were not updated to reflect multiple residents’ changing conditions, including new or worsening pressure injuries, a wound, falls, and medication-related needs. A resident with recurrent sacral and ischial pressure injuries, another with a heel wound that declined to stage 3, and others with new skin issues or repeated falls had records showing the events, but the care plans did not consistently include the new problems, refusals, or individualized interventions. One resident’s falls plan was revised late and did not address the cause of the fall, and another resident’s plan did not identify use of a palm guard or antibiotic/antiviral therapy.
Medication refrigerators in one med storage room were not maintained at the proper temperature. Surveyors observed a full-sized refrigerator and a compact refrigerator storing insulin and IV meds, with logs showing repeated temperatures below the required 36 to 46 degrees F range and thermometers reading 30 degrees F and 34 degrees F. The RNUM agreed the refrigerators were not at the correct temperatures, and the NHA and DON were informed.
Two residents were involved in an incident where a confused resident entered another resident’s room, grabbed the resident’s forearm, and caused pain and fear; although this was documented in the EHR and leadership was notified, no facility‑reported incident or investigation could be produced. In a separate event, the same resident was later found with a head abrasion of unknown origin; the facility’s investigation lacked factual findings, did not include interviews with the CNA and LPN who first identified and documented the injury, and was initiated several days after the injury was discovered, contrary to facility policy requiring prompt reporting and investigation of alleged abuse and injuries of unknown origin to appropriate authorities.
The facility failed to conduct timely and thorough investigations into a resident-to-resident altercation and a head injury of unknown origin. In one incident, a confused resident entered another resident’s room, grabbed the resident’s forearm, and caused pain and fear; although staff intervened and notified leadership, no investigation or Facility Reported Incident documentation could be produced. In a separate event, the same confused resident was later found with a head abrasion during a skin check, but the investigation began three days after discovery, omitted interviews with the CNA and LPN who first identified and documented the injury, and left the factual findings section blank, contrary to facility policy requiring comprehensive, immediate investigations.
Surveyors identified a 30% medication error rate when two residents received multiple medications outside the facility’s 60-minute administration window and one extended-release potassium tablet was improperly split. One RN gave tramadol and omeprazole significantly later than the ordered time, and another RN administered several scheduled morning medications, including atorvastatin, Vitamin D3, sertraline, Tylenol, propranolol, potassium ER, and Eliquis, well past the allowed time frame while also breaking the potassium ER tablet in half, contrary to its extended-release design.
Failure to Honor Resident Shower Preference: A resident with intact cognition and diagnoses including anxiety, dementia, and depression was not consistently accommodated for a preferred morning shower schedule. The care plan listed shower preferences, but the resident was scheduled for an evening shower on one day and repeatedly refused because the resident did not want to go to bed wet, have wet hair, or be cold. Records did not show alternative shower times or options being offered, and unit management and the DON acknowledged that resident shower preferences should be honored.
A resident with intact cognition, anxiety, depression, and age-related physical debility filed a grievance after two pairs of pants went missing from the room. The grievance was confirmed, but there was no evidence the documented resolution to replace the pants was carried out, and later interviews showed the resident never received new pants or reimbursement.
The facility failed to provide written transfer and bed hold notices for two residents who were sent to the hospital. One resident with intact cognition was transferred after a fall, and another resident with intact cognition and an activated POA was hospitalized twice for low blood pressure and later chest pain and difficulty breathing. Survey review found no written transfer or bed hold notices in either record, and staff described a process of sending forms with the resident or giving verbal notice, while also stating that Medicaid residents typically did not receive a bed hold agreement.
A resident with stroke-related left-sided weakness and cognitive impairment was observed using a left palm guard, but the device was not documented in the care plan, CNA care list, or physician orders when first identified. Staff could not initially provide information about the device, and the therapy assessment and physician order were only obtained after surveyor inquiry.
A resident admitted with an indwelling catheter did not have a baseline catheter care plan or a comprehensive catheter care plan in place, and the catheter bag was repeatedly observed without a privacy cover and at times visible from the hallway or dragging on the floor. The resident stated they preferred a cover over the catheter bag, while nursing staff and management acknowledged the care plan should have been initiated on admission and that a privacy cover should be provided when preferred.
A resident with acute and chronic respiratory failure, CHF, and mantle cell lymphoma was observed receiving oxygen by NC at 2 LPM, but the chart had no physician order or MAR documentation for oxygen administration. The facility policy required a physician order and documentation of the flow rate, route, and rationale, and an RN confirmed the resident had no oxygen order before a later order was obtained.
Pharmacy medication review recommendations were not acted upon for two residents. One resident with multiple diagnoses, including insomnia and malnutrition, had repeated pharmacist concerns about trazodone and a PRN antipsychotic order lacking a valid stop date, with no documentation that the MD was consulted or the issues were addressed. Another resident admitted with respiratory failure, lymphoma, and pneumonia continued receiving levofloxacin without an end date even though a PA note listed a last day of use and the pharmacist flagged the missing duration for use.
Incomplete antibiotic and antiviral orders with missing stop dates and indications: Surveyors found two residents with medication regimens that were not fully documented. One resident receiving IV vancomycin and PO Flagyl had no stop dates, and Flagyl lacked a diagnosis/indication. Another resident had Acyclovir, Levofloxacin, and Bactrim-DS ordered without proper stop dates or correct indications on the MAR, despite a PA note showing Levofloxacin had an end date and the other drugs were prophylaxis for mantle cell lymphoma.
The facility failed to consistently maintain and accurately update daily nurse staffing postings. Several required daily postings were missing, and on two occasions the NOC shift postings listed more CNAs than were actually scheduled. The staff member responsible for updating postings acknowledged that the information should have been corrected and that the missing postings should have been available, resulting in inaccurate posted information about licensed staff directly responsible for resident care for all residents.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors.
A resident's allegation of abuse by a CNA was not documented as reported to the State Survey Agency within the required two-hour timeframe. The facility's incident report remained in draft status with missing submission details, and there was no verifiable evidence that the initial report was made promptly, as required by policy.
A resident with a diabetic foot ulcer did not have a complete medical record after the facility changed wound care providers and lost access to the previous provider's documentation. The facility was unable to provide the wound assessments from the former contracted wound MD, resulting in missing clinical records for the resident.
The facility failed to ensure the safety of two residents from accidents and hazards. One resident experienced multiple falls without appropriate risk assessments or interventions, while another was struck by a Hoyer lift during a transfer, with the incident going unreported and without preventive measures. These deficiencies highlight the facility's inability to adequately supervise and protect residents.
A resident with Alzheimer's and chronic pain experienced discrepancies in their medication administration records. The MAR showed fewer administrations of Morphine than the controlled drug log, with the actual administration documented more times than reflected in the MAR. Interviews with staff revealed late entries and inconsistencies in documentation, leading to inaccurate records.
A resident with chronic conditions developed pressure injuries on both heels due to the facility's failure to timely revise care plans and conduct comprehensive assessments. Despite having a policy for pressure injury management, the facility did not adhere to it, resulting in the resident's left heel injury worsening to an unstageable ulcer. Interviews revealed gaps in documentation and communication among staff.
Two dishwashing machines in the facility's unit kitchens were leaking water onto the floor, and one lacked a functioning temperature display, posing potential hazards. The issues were acknowledged by the Dietary Manager, who mentioned a maintenance request was submitted. However, the Director of Facilities had not formally requested service until prompted by the surveyor, and a part was awaited for repairs. These deficiencies potentially impacted all 24 residents on the affected units.
Two residents at the facility did not have their Do Not Resuscitate (DNR) forms in their medical records, contrary to facility policy. One resident, with impaired cognition and an activated power of attorney, and another cognitively intact resident, both lacked the necessary documentation. The facility's administration was unable to locate the forms and was in the process of obtaining new signed forms.
A resident's visitation rights were restricted after an alleged abuse incident involving a family member. The facility required supervised visits but failed to provide supervision on weekends, limiting access. The administration did not communicate visitation requirements to the family member, and the social worker did not document or assess the impact of restricted visits on the resident.
A resident with a history of cerebral infarction and other conditions was improperly transferred using a Hoyer lift by a single staff member, contrary to the care plan requiring two staff members. This resulted in a bruise on the resident's forearm, exacerbated by medications increasing bleeding risk. The facility's investigation confirmed the neglect in following the care plan.
A resident experienced verbal and physical abuse by a family member, which was not reported to the NHA or State Agency within the required timeframe. The facility's staff, including an RN and CNAs, witnessed the abuse but delayed reporting it. Additionally, an allegation of neglect involving the resident being left in a wheelchair for 40 hours was not reported, as the RN dismissed it as implausible. These incidents were identified during a survey, revealing deficiencies in the facility's reporting procedures.
A facility failed to thoroughly investigate allegations of verbal and physical abuse, as well as neglect, involving a resident. The verbal abuse by the resident's daughter was not fully explored, and the physical abuse allegation was not investigated until a month later. Additionally, a neglect claim that the resident was left in a wheelchair for 40 hours was dismissed by an RN without proper investigation or documentation.
A resident with Alzheimer's Disease experienced restricted visitation with a family member after alleged abuse, but the facility failed to assess or monitor the impact on the resident's well-being. The social worker did not document interactions or update the care plan, and the family was not informed about visitation requirements, violating the facility's social services policy.
The facility failed to promptly resolve grievances for four residents, including issues with not being dressed, not getting out of bed until the second shift, and not receiving showers. The facility did not follow up with the residents or their representatives and did not document the date written decisions were issued, violating their grievance policy.
A resident with multiple diagnoses, including Parkinson's Disease and CKD, did not receive consistent assistance with showering as per their care plan. Documentation showed gaps and inconsistencies in the provision of showers, and staff interviews revealed a lack of awareness and recollection regarding the resident's needs.
A resident with multiple diagnoses, including stroke and diabetes, experienced significant weight loss, but the facility failed to obtain weekly weights as ordered by the physician over an eleven-week period. Despite the facility's weight monitoring policy, the required weekly weights were not documented on several occasions.
Failure to Assess, Treat, and Prevent Pressure Injuries
Penalty
Summary
The facility did not ensure consistent pressure injury assessment, treatment, offloading, and care plan revision for multiple residents with existing pressure injuries or high risk for skin breakdown. One resident was admitted with a stage 3 sacral pressure injury, was assessed as high risk for pressure injury development, and had additional factors including immobility, incontinence, malnutrition, diabetes, and hospice status. Survey observations showed the resident’s heels were not offloaded and were lying directly on the mattress on multiple occasions. The resident’s admission wound orders were not implemented as written, the initial comprehensive assessment of the sacral wound was delayed, and later reopening of the sacral wound was documented without a root cause analysis or care plan revision. The same resident’s sacral wound reopened more than once and later developed new pressure injuries to both ischial areas, with no documented root cause for the new wounds or the decline in the right ischial wound. Nursing documentation did not consistently show ordered sacral treatments were completed. The record also showed the resident’s air mattress was not functioning at one point, and staff interviews reflected uncertainty about when support surfaces were changed or whether the resident was on an air mattress. The wound physician later documented a stage 4 sacral wound, then stated that staging was an error and the wound should have remained stage 3 until it resolved. Another resident admitted without skin concerns developed a fluid-filled blister on the right heel that was not comprehensively assessed or care planned until several days later. The blister later declined to an unstageable pressure injury and then to a stage 3 heel pressure injury. Nursing documentation on the treatment administration record did not consistently show ordered treatments were completed, and the resident was observed not wearing heel boots with feet flat on the floor. The record also showed a resident admitted with a heel pressure injury did not have preventative interventions identified until after a new heel wound developed on the opposite foot and the original wound worsened. Additional residents developed pressure injuries or worsening wounds without timely comprehensive assessments, root cause analysis, or care plan revisions, including a resident whose heel DTI reopened and progressed to an avoidable stage 3 pressure injury, and residents whose buttock and sacral DTIs or pressure injuries declined after wounds were discovered without complete assessment documentation.
Failure to Perform Root Cause Analysis and Individualize Fall Prevention After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, thorough post-fall assessments, and timely, individualized care plan revisions to prevent accidents for multiple residents reviewed for falls. The facility’s own fall policy required completion of a fall risk assessment after every fall, evaluation of the area where the fall occurred for possible contributors, documentation of identified interventions, and 72-hour observation after a fall. However, for several residents, falls were not thoroughly assessed to determine root causes, contributing factors such as incontinence or transfer needs were not evaluated, and fall care plans were not promptly or appropriately updated to address identified risks. One resident with diabetes, COPD, osteoarthritis, and a history of right fibula fractures was cognitively intact and occasionally incontinent of bladder, but had no toileting program and no assessment of incontinence as a fall risk factor. This resident had an unwitnessed fall in the bathroom while self-transferring from the toilet, resulting in facial bruising and swelling. The fall care plan was revised only to include re-education to call for assistance and placement of a “Call No Fall” sign, with no documented evaluation of urgency, frequency, or incontinence as contributors and no toileting-related interventions. Later, the same resident had an unwitnessed fall from bed resulting in a fractured right fibula; the fall scene investigation contained unclear handwritten notations, contradictory information about footwear, a blank root cause analysis section, and no documented assessment of bladder incontinence or toileting needs as potential contributors. The falls care plan was not revised after this second fall, and the resident’s bed was observed not in the lowest position despite documentation that this was an intervention. Another resident with diabetes, orthostatic hypotension, cirrhosis with ascites, compression fracture, osteopenia, and atrial flutter was cognitively intact and required extensive ADL assistance, with an order for a blood thinner. The ADL care plan listed all transfer types and assistance levels without individualization. Therapy evaluated this resident and recommended maximum assistance of two with a non-motorized sit-to-stand device and gait belt, but this recommendation was not added to the ADL care plan before a witnessed fall occurred during a pivot transfer with one-person assistance. Staff reported that the CNA worksheet, derived from the care plan, contained multiple and conflicting transfer instructions, and the care plan had not been updated with the therapy recommendation until two days after the fall. A cognitively intact hospice resident with spinal degeneration and Alzheimer’s disease had a falls care plan with generic interventions, including keeping the bed at an “appropriate height” without clarification. This resident had an unwitnessed fall from bed, stating they were trying to get to their son. The fall scene investigation documented impaired mentation and rolling out of bed as factors, but omitted key sections such as footwear, affect prior to the fall, recent medication changes, and environmental factors. The root cause was documented only as confusion, the interventions section was left blank, and there was no IDT root cause analysis form provided. The falls care plan was not revised until eight days later, when a fall mat was added, and later observation showed the bed at hip height with no fall mat in place. Another resident with a stroke, left-sided weakness, cognitive impairment, and dependence on staff for dressing and hygiene had a falls plan of care with only generic interventions and no individualized fall prevention measures. The resident care guide’s safety section contained no fall interventions, despite the resident being incontinent and requiring one-person assistance for transfers and ADLs. This resident experienced multiple unwitnessed falls in the facility, including falls from bed that resulted in hospital transfers. For at least one fall, the documented root cause was that the resident “wanted something to eat,” but there was no supporting documentation for this conclusion and no documented interventions or care plan revisions to prevent recurrence based on that or any other possible etiology. Across these cases, staff interviews revealed uncertainty about who was responsible for updating care plans after falls, with an LPN stating they had never updated a care plan and believed unit managers did so, and a unit manager acknowledging that root cause analyses had not been done for a period due to lack of unit managers. CNA worksheets used for daily care were generated from the care plans and, in at least one case, contained multiple, conflicting transfer instructions because the care plan itself was not individualized. These actions and inactions resulted in falls not being thoroughly assessed, root causes not being clearly identified or documented, and fall care plans not being promptly or adequately revised to address resident-specific risks such as incontinence, transfer method, bed height, and use of fall mats.
Failure to Reassess Dementia-Related Behaviors and Document Resident-to-Resident Aggression
Penalty
Summary
The facility did not provide appropriate treatment and services for a resident with dementia and behavioral symptoms to allow the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident had severe cognitive impairment, wandering/elopement risk, and a history of behaviors directed toward others, including entering other residents’ rooms, yelling, combativeness, refusal of care, and aggression toward staff. The resident’s care plans addressed wandering and behaviors with interventions such as redirection, calm communication, activity involvement, and later a geri-psych consult, but the record did not show a comprehensive reassessment of behavioral interventions despite ongoing and escalating behaviors. The resident’s record contained multiple progress notes documenting repeated behavioral incidents over the course of the stay, including entering other residents’ rooms, laying in other residents’ beds, attempting to hit staff, pulling a fire alarm, exit seeking, combative episodes, and aggression during showering. The resident also had a decline in BIMS score from 6 to 2, and the annual MDS documented physical behavioral symptoms directed toward others and rejection of care. Survey review found no formal behavior monitoring or tracking system in place to track frequency, triggers, or effectiveness of interventions, and the resident’s behavioral interventions were not reassessed in response to the ongoing pattern of behaviors. A resident-to-resident altercation occurred when the resident entered another resident’s room and grabbed the other resident by the forearm, causing pain and fear. The other resident reported being scared and stated the incident hurt. Survey review found that this incident was not documented in the resident’s own electronic record, limiting the facility’s ability to reassess risk and revise behavioral interventions. The record also showed a prior similar incident in which the resident grabbed the same other resident’s forearm, but that event likewise was not documented in the resident’s record. Staff interviews indicated the resident had a history of wandering into rooms and aggression, and one staff member stated that if a resident hit staff, a psych consult should be obtained; however, the resident did not receive a psych consult until January 2026.
Failure to Maintain Required BID Screening
Penalty
Summary
The facility did not ensure it did not employ individuals who were found guilty of abuse, neglect, exploitation, or mistreatment because it failed to complete a background information disclosure (BID) every four years for 1 of 13 staff reviewed, the Director of Facilities Management-W. The facility policy on Abuse Prevention states that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and that the community will not knowingly employ or engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. During record review, the surveyor found that the employee file for DFM-W, whose hire date was documented as 2/6/2019, contained a BID dated 1/16/2019 but no BID completed within the last four years. The surveyor reviewed facility employee files on 1/26/26 and could not locate a current BID in the file. In an interview on 1/27/26, the NHA stated they would contact HR regarding any additional BID for DFM-W, and later provided an updated BID dated 1/27/26. The NHA stated the HR department was not aware the BID needed to be completed every four years.
Resident Records Stored Uncovered and With Maintenance Items
Penalty
Summary
Resident medical records were not safeguarded against loss, destruction, or unauthorized use. During a tour of the medical records storage area in the basement level of the attached convent unit, the surveyor observed several boxes of resident medical records sitting directly on the floor and several boxes left uncovered without protective lids. The storage room was locked with a code, but the Director of Facilities Management stated he had access to the room to retrieve durable medical equipment and was not sure who else had access, including whether staff from the convent side of the campus could enter the room. The storage room also contained durable medical equipment and maintenance items, including wheelchair parts and mattresses, and the Nursing Home Administrator confirmed that older resident records and previous resident records were kept in that basement room while current resident records were kept in the Medical Records Assistant's office. The Medical Records Assistant stated the room had become very disorganized and that the long-term plan was to move the records so the room could be used for maintenance needs instead. The surveyor noted that confidential resident information was being stored in the same room as maintenance department storage.
QAPI Program Failed to Identify Systemic Deficiencies
Penalty
Summary
The facility’s QAPI/QAA program did not identify and correct systemic deficiencies before the survey. Survey findings documented 27 deficiencies during the recertification, complaint, and extended survey, including actual harm at F686 for treatment and services to prevent and heal pressure ulcers, F689 for freedom from accident hazards, and F744 for treatment and services for dementia. The scope and severity at F606 and F686 were identified as substandard quality of care, and widespread deficient practice was cited at multiple tags including F865 for the QAPI program, F868 for the QAA committee, F880 for infection prevention and control, F881 for the antibiotic stewardship program, F882 for designation of a dedicated infection preventionist, and F944 for QAPI training. The facility’s QAPI plan stated that it should focus on systems and processes, identify and improve system gaps, and use data to guide operations. Appendix A listed quality improvement measures for community acquired pressure injuries, rehospitalizations/ED visits, and falls with major injuries, with approaches such as reviewing Braden assessments, skin checks, dietician evaluation, fall risk assessments, and tracking and trending data at QAPI meetings. However, the surveyor noted that the 2026 QAPI plan did not document systemic problems related to infection control and prevention, including the antibiotic stewardship program and infection preventionist role, dementia care and treatment, or timeliness of medication administration. During interviews, the NHA stated the facility was planning to implement a paper log for behavior monitoring and had identified gaps in clinical oversight, but this monitoring had not already been in place. The NHA also stated the facility had recently identified concerns with falls and wounds and had started PIPs for those areas, but they were not yet fully implemented. When asked about infection prevention, the NHA stated the facility was recruiting for an IP and that the NHA, DON, and quality director or corporate support were covering the role, with no single person designated as the IP at QAPI meetings. The NHA further stated the facility had multiple problems since starting in October 2025, including falls and wounds, but did not identify all issues found during the survey, and there was no evidence the QAPI program had made a good faith attempt to correct the systemic problems related to late medications and infection control.
QAPI Committee Missing Required DON Attendance
Penalty
Summary
The facility did not maintain a quality assessment and assurance committee with the required members to identify issues through the committee. The report states that the facility's QAPI program was intended to include input, participation, and responsibility at all levels, and that the QAPI committee members included the director of nursing (DON). However, review of the facility's QAPI attendance sign-in sheets and meeting minutes showed that the DON did not sign in for 4 of 10 months reviewed. On 1/27/26, the surveyor reviewed QAPI attendance records provided by the Nursing Home Administrator (NHA) and found meeting minutes for February through December 2025. The QAPI meeting minutes for 2/7/25, 6/19/25, 7/1/25, and 11/3/25 documented attendees, but the sign-in sheets did not include the DON. When asked who attended QAPI meetings, the NHA stated that the DON, Medical Director, MDS coordinator, social services, NHA, maintenance, dietary services, activities, admissions, and corporate support attended monthly, and that the pharmacist consultant attended quarterly. No additional information was provided to explain why the DON did not attend those four QAPI meetings.
Infection Control Program Not Effectively Implemented
Penalty
Summary
The facility did not implement an effective infection prevention and control program. Record review and staff interviews showed the facility did not maintain documentation of ongoing infection surveillance, and the surveillance process was still being compiled during the survey. The facility also did not have documentation of preventive actions or investigation related to two COVID outbreaks in August 2025 and September 2025; the only outbreak documentation available was a line list. The facility policy stated the infection prevention and control program included surveillance, data analysis, outbreak management, and records of incidents and corrective actions related to infections. The facility also did not implement isolation and enhanced barrier precautions consistently for multiple residents. R66 was observed with a contact precaution sign, but staff entered the room without wearing gowns as indicated by the facility’s contact precaution sign. LPNs and CNAs interviewed gave inconsistent answers about whether R66 required contact precautions or enhanced barrier precautions, and the DON later stated R66 did not have MRSA and was changed to enhanced barrier precautions because of a urinary catheter and wounds. The record review did not find documentation supporting MRSA for R66. R67 was admitted with an indwelling catheter, surgical and vascular wounds, a PICC line, and MRSA in the right foot wound, yet there was no contact precaution sign on the door on multiple observations. Surveyors observed R67’s catheter bag hanging from the wheelchair and later lying on the floor without a protective barrier. CNA-Q entered the room without appropriate PPE and assisted with the resident’s foot without gown use. Staff interviews showed confusion about what precautions R67 required, and RNUM-C confirmed R67 should have been on contact precautions when admitted. R4 had an indwelling urinary catheter and was observed with the catheter bag hanging from a garbage can without a protective covering. CNA-Q emptied the catheter bag and then provided incontinence care and dressing assistance without changing gloves or performing hand hygiene between tasks, and did not perform hand hygiene after disposing of PPE. The facility later stated the catheter bag should not have been hung on the garbage can, and there was no evidence that risk versus benefits or alternatives had been discussed with the resident.
Lack of Antibiotic Stewardship Monitoring and Documentation
Penalty
Summary
The facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Based on record review and interview, the facility also did not have documentation of antibiotics being administered in the facility, including the indications for use, duration, isolation, organism, administering for definition of infection criteria. The deficiency was identified as affecting all 53 residents in the facility. The facility policy titled Antibiotic Stewardship, dated 6/25, stated that antibiotics shall be prescribed and administered under the guidance of the community's antibiotic stewardship program and that the infection preventionist will track antibiotic use, monitor adherence to evidence-based criteria, and compile reports related to antibiotic usage and resistance data. During surveyor interviews, the NHA and DON stated the QD was in training and would gather IPCP documents, and later stated they were still compiling the requested infection surveillance. On review of the IPCP and Facility Assessment, the facility did not have a designated, qualified IP, and the antibiotic compiling sheets provided did not document antibiotics being used in the facility to determine whether infections met criteria for antibiotics, including residents on antibiotics upon admission or those acquired in the facility, the indications for use, organism, duration, and appropriate isolation.
No Designated Infection Preventionist
Penalty
Summary
The facility did not have a designated, qualified Infection Preventionist (IP) responsible for implementing the Infection Prevention and Control Program (IPCP). During record review and interview, the Nursing Home Administrator (NHA) and Director of Nurses (DON) stated that the Quality Director was in training and had not fully started in the role, while the NHA and DON were overseeing the IPCP. The facility assessment did not document a facility IP, and no additional information was provided to explain why a designated infection preventionist was not in place. The facility policy stated that the IPCP is to be coordinated and overseen by the infection preventionist and is a facility-wide program involving surveillance, policy oversight, antibiotic stewardship, outbreak management, and education. Surveyor interviews on 1/20/26 and 1/26/26 confirmed that the Quality Director had come to the facility on January 14, 2026, and was contracted for 30 days, but was still in training. The report states that there was not a designated, and qualified, IP at the facility, and that the NHA and DON were overseeing the program instead.
Failure to Ensure Annual QAPI Training for Direct Care Staff
Penalty
Summary
Mandatory QAPI training was not ensured for all staff when 2 of 5 direct care staff reviewed, CNA-DD and CNA-EE, did not have documentation showing they received annual Quality Assurance and Performance Improvement training. The facility policy stated that all staff are to receive training appropriate to their roles and responsibilities, including ongoing and annual training, and that all staff shall participate in ongoing education based on QAPI activities. On 2/4/2026, the surveyor requested annual training and education hours for 5 employees and reviewed the records. The surveyor found no documented QAPI training for CNA-DD and CNA-EE. The NHA was informed that the training could not be located and stated the facility did not currently have a staff educator, although a unit manager with an educational background had been helping oversee staff training. No additional information was provided at the time of the write-up.
Failure to Comprehensively Assess Wounds and Post-Fall Status for Multiple Residents
Penalty
Summary
The deficiency involves multiple failures to comprehensively assess residents and provide treatment and care in accordance with professional standards and facility policy. One resident with diarrhea related to IV antibiotics reported red, raw skin on the buttocks; nursing documentation later identified maceration in the gluteal fold but did not include measurements or tissue descriptors, and there was no documentation that a physician or NP was notified of this new skin breakdown. An antifungal powder was documented as being applied without a corresponding provider order, and the medicated powder—brought from a prior hospitalization—was being applied by a CNA rather than a licensed nurse. Subsequent skin documentation referenced “existing wounds” without specifying which wounds or describing them. Another resident was admitted with cellulitis of the right lower limb, diabetes, diabetic foot ulcers, and chronic non‑pressure ulcers. The record showed multiple documented wounds on admission, but there was no assessment or descriptive documentation of the right lower leg cellulitis itself, despite progress notes stating the cellulitis was being monitored. A treatment order to cleanse with normal saline or wound cleanser and apply betadine daily did not specify the anatomical location where the treatment was to be applied. The wound nurse later stated that non‑pressure wounds such as cellulitis were expected to be assessed and documented by floor nurses or the Unit Manager, and that she had noticed and changed the nonspecific order only after her first wound assessment. A third resident, cognitively intact and on Xarelto for atrial flutter, experienced an unwitnessed fall from bed, landing face down with the face resting on the metal base of an overbed table. Staff moved the table, rolled the resident, placed the resident on a mechanical lift sling, and transferred the resident to bed before contacting the NP. The resident had abrasions to the forehead, nose, and knee, a blood pressure of 86/57 with a pulse of 98, and altered mental status compared to prior documentation that the resident was alert and able to make needs known. EMS documentation indicated the resident was found in bed, was only oriented to person, had a weak pulse, and that the fall had occurred approximately 30 minutes before EMS arrival. Staff called a private ambulance service rather than 911, and the NP reported not being given any vital signs when notified of the fall. Another resident with Alzheimer’s disease and on hospice had an unwitnessed fall, was found on the floor, and reported back pain rated 10/10. The facility’s neuro assessment flow sheet and the DCO’s interview confirmed that neurological checks after a fall were to be completed every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for the next 2 hours, every 2 hours for the next 8 hours, every 4 hours for the next 12 hours, and then every shift for 48 hours. However, neurological assessments for this resident were only documented at six time points over approximately three hours, with gaps that did not follow the required frequency and no further neuro checks recorded after 1:20 PM. A fifth resident developed a new skin wound that was not comprehensively assessed for etiology or documented with appropriate interventions to promote healing. Although an NP ordered a wound consult on the same day the wound was identified, the consult was not completed. This resident also had an unwitnessed fall while on blood‑thinning medication and was unable to communicate whether the head was struck; despite this, a thorough neurological assessment was not completed post‑fall, contrary to the facility’s falls policy and neuro‑check protocol. Collectively, these events show repeated failures to perform complete assessments, obtain and follow appropriate treatment orders, and adhere to established neuro‑assessment and falls procedures for residents with new wounds, cellulitis, and unwitnessed falls, including those on anticoagulants and with head injuries.
Failure to Administer Medications Timely and as Ordered for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders and facility policy, including timeliness standards, for multiple residents. One resident with generalized anxiety disorder, severe cognitive impairment (BIMS score of 5), anxiety, and depression had a scheduled order for hydroxyzine 10 mg three times daily beginning mid-September. The MAR showed numerous instances where the hydroxyzine doses were administered outside the facility’s stated 1-hour before/after window, including morning, noon, and afternoon doses given significantly late on multiple days. The same resident’s hydroxyzine was also discontinued on one date and not restarted until two days later, resulting in missed doses, and when restarted with a new three-times-daily schedule, there were additional late administrations and at least one dose left blank, indicating it was not administered. The same resident’s hydroxyzine order was changed by a nurse practitioner from scheduled to PRN, and a subsequent progress note documented that an LPN contacted the practitioner to clarify the order after a family member reported what medication the resident was supposed to be receiving. At that time, the LPN noted there was no active order in the record, and a verbal order was given to restart the hydroxyzine. The facility’s MARs for September and October continued to show repeated late administrations of the hydroxyzine outside the scheduled time frames, including multiple morning doses given more than an hour after the scheduled time and some evening doses given early or late. The unit manager later stated she did not know who reviews provider assessments after visits, was unaware of who uploads them into the charts, and acknowledged that no one was currently reviewing them. Additional deficiencies were identified for other residents. One nurse administered multiple 8:00 AM medications, including atorvastatin, vitamin D3, sertraline, acetaminophen, propranolol, potassium ER, and apixaban, at 11:01 AM, two hours past the allowable window, and reported being pulled to other units to administer IV medications, with other residents’ 8:00 AM medications still pending. Another nurse administered 7:00 AM medications, including tramadol and omeprazole, after the allowed time window. A resident receiving IV cefepime 2 g every eight hours for a catheter-associated UTI had three initial doses not given because the medication had not arrived from the pharmacy, one dose documented as administered five and a half hours early, and several later doses not signed out at all. The DON later stated that a night-shift RN had come in early to hang IV medications and thought they had been signed out, but the MAR still lacked signatures for those doses when re-reviewed. The facility’s written policy required medications to be administered per orders within a 60-minute before/after window, which was not followed in these instances.
Care plans not revised for new wounds, falls, and treatment needs
Penalty
Summary
The facility did not ensure comprehensive care plans were developed, reviewed, and revised to reflect residents’ changing conditions and identified problems. Multiple residents had new wounds, pressure injuries, falls, or medication-related needs that were documented in the record, but those issues were not added to their care plans or were not revised in a timely manner. The report states that the facility policy required care plans to incorporate identified problem areas, risk factors, and current standards of practice, and to be revised as residents’ conditions changed. R6 had a history of a stage 3 sacral pressure injury that healed and reopened twice, later developed pressure injuries to both ischiums, and had documented refusals of repositioning and heel offloading. The care plan was not revised to address the reopened sacral wound, the new left and right ischial pressure injuries, the decline of the right ischial wound to stage 3, or the refusals of repositioning and heel offloading. Survey observations also noted R6’s heels were not being offloaded as planned. R46 developed a fluid-filled blister to the right heel that later declined to a stage 3 pressure injury, and the care plan was not revised promptly after the blister was identified or to address the decline, refusals of treatment, or the resident’s preference-related needs. R1 developed a deep tissue injury to the left buttock, but the pressure injury was not added to the care plan. R49 developed a stage 3 sacral pressure injury, but the care plan did not reflect the current wound or related interventions. The report also identified care plan omissions related to falls and other interventions. R5 was observed with a left palm guard in use, but the device was not identified on the care plan; R5 also developed a wound on the sole of the left foot and had multiple unwitnessed falls, yet the care plan did not include the new wound or fall-prevention interventions. R58 had an unwitnessed fall that resulted in a fractured distal fibula requiring surgical repair, but no revisions were made to the Falls Care Plan to address future fall prevention. R38 had an unwitnessed fall and the Falls Care Plan was revised eight days later with an intervention that did not address the cause of the fall. The report also states R1’s care plan did not identify the use of antibiotics and an antiviral medication for targeted health concerns or their side effects.
Medication Refrigerators Stored Drugs at Improper Temperatures
Penalty
Summary
Drugs and biologicals were not stored at the proper temperature in the medication storage room on the west side of the facility. During observation with the RNUM, the room contained two refrigerators, including a full-sized refrigerator with a freezer and a small compact refrigerator, and medications such as insulin and intravenous medications were stored in both units. The temperature logs posted on the front of each refrigerator stated that temperatures should be logged daily and that temperatures out of range of 2 degrees to 8 degrees C, or 36 degrees to 46 degrees F, should be re-checked and action logged. The January temperature log for the full-sized refrigerator had entries for 17 of 26 days, and 16 of those documented temperatures were below 36 degrees F. The surveyor observed the thermometer inside that refrigerator reading 30 degrees F. The compact refrigerator log had entries for 20 of 26 days, and 16 of those documented temperatures were below 36 degrees F. The surveyor observed that thermometer reading 34 degrees F. The RNUM agreed the refrigerators were not at the correct temperatures, and the NHA and DON were informed that the west-side medication refrigerators were being maintained at temperatures ranging from 29 to 35 degrees F.
Failure to Report and Adequately Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report and thoroughly investigate alleged abuse and an injury of unknown origin, and to report these incidents to the State Agency as required by facility policy. One incident occurred when a confused resident entered another resident’s room; the resident in the room told the other to leave, but the intruding resident grabbed the resident’s forearm, causing the resident to scream in fear and experience forearm pain. A nursing progress note documented this resident‑to‑resident incident and that staff intervened, separated the residents, and notified leadership. However, there was no corresponding facility‑reported incident or investigation provided for this event, and the current NHA, who was not employed at the time, was unable to locate any prior investigation related to the incident. A second deficiency relates to an abrasion to the head identified as an injury of unknown origin for the same resident who had entered the other resident’s room. The facility produced an investigation document noting a skin abrasion and marks of unknown origin, with references to fall protocol review, staff statements, skin assessment, notifications, and neuro checks, but the factual discoveries section was left blank. The CNA and LPN who first identified and documented the injury on a shower sheet and in a progress note were not interviewed as part of the investigation. The DON acknowledged not knowing the source of the injury and could not explain why the investigation began three days after the injury was found, despite the facility’s abuse policy requiring immediate reporting and investigation of alleged abuse and injuries of unknown origin, including notification of the State Agency.
Failure to Timely and Thoroughly Investigate Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into an alleged resident-to-resident abuse incident and an injury of unknown origin. One resident reported that another confused resident entered the room, was told to leave, then grabbed the resident’s forearm, causing the resident to scream in fear and experience forearm pain. This event was documented in a nursing progress note as occurring during the evening shift, with staff intervening, separating the residents, and notifying leadership. However, when surveyors requested the investigation related to this resident-to-resident altercation, the current Nursing Home Administrator was unable to locate any investigation, and the DON stated that the former administrator would have handled it. No Facility Reported Incident investigation or related investigative documentation was provided for this event, despite facility policy requiring assignment of an investigation, interviews with staff on all shifts who had contact with the resident, and review of events leading up to the alleged incident. The facility also failed to promptly and thoroughly investigate an injury of unknown origin involving the same confused resident who was later found to have a skin tear/abrasion to the head during a skin check. The injury was identified and documented in the resident’s record, but the investigation was not initiated until three days later. The written investigation for the head abrasion stated that fall protocol was reviewed, staff statements were collected, a skin assessment was completed, and appropriate parties were notified, but the factual discoveries section was left blank. Surveyors noted that the CNA and LPN who first identified and documented the injury on the shower sheet and in the progress note were not interviewed, and the DON could not explain the source of the injury. The NHA stated that such a head injury would be considered an injury of unknown origin and that the expectation was for immediate initiation of an investigation, including review of history, resident and staff interviews, and review of interventions, which did not occur as required by facility policy.
High Medication Error Rate Due to Late Administration and Improper Alteration of ER Tablet
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, resulting in a calculated error rate of 30 percent (9 errors out of 30 opportunities) during a medication pass observation. Facility policy titled "Administering Medications" dated 12/2025 required medications to be administered in accordance with orders and within a 60-minute window before and after the scheduled time. During observation on the morning of 1/21/2026, a registered nurse administered tramadol 50 mg and omeprazole 40 mg to one resident at 8:27 AM, although these medications were scheduled for 7:00 AM, placing them outside the allowable administration time frame. Later that morning, another registered nurse was observed preparing and administering multiple medications to a second resident, including atorvastatin 20 mg, Vitamin D3 200u, sertraline 50 mg, Tylenol 1000 mg, propranolol 60 mg, potassium ER 20 mEq, and Eliquis 5 mg. These medications were scheduled for 8:00 AM but were administered at 10:55 AM, again outside the facility’s defined time window. During this same pass, the nurse broke the potassium ER 20 mEq tablet in half, despite it being an extended-release formulation that is not to be broken or crushed due to its coating. The nurse reported being pulled to another unit to administer IV medications, which contributed to being behind schedule with medication administration on the unit. These observed late administrations and the improper alteration of an extended-release medication comprised the identified medication errors.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to support a resident’s right to self-determination by not accommodating the resident’s preference for morning showers. The resident was admitted with diagnoses including anxiety, unspecified dementia, depression, and need for assistance with personal care, and had a BIMS score of 15 indicating intact cognition. The care plan documented that the resident preferred showers and that showers were scheduled for Saturday AM and Wednesday AM, but the resident stated the actual schedule was Tuesday evening and Saturday morning and that the resident preferred showers in the morning. Survey review found the resident repeatedly refused Tuesday evening showers because the resident did not want to go to bed wet, did not want hair wet, had a cold, or did not want to be cold, and the record did not document that a shower was offered at another time or that alternative bathing options were provided. The resident’s charting also showed multiple Tuesdays when no shower or bath was received, and there were no care plan revisions addressing the resident’s refusal pattern or the mismatch between the resident’s preference and the scheduled shower times. Interviews with unit management and the DON confirmed that resident preference should be honored and that shower schedules should accommodate AM or PM preferences.
Failure to Resolve Resident Grievance About Missing Clothing
Penalty
Summary
The facility did not ensure that 1 resident who filed a grievance received corrective action or resolution follow-up from the facility. The resident, who had diagnoses including age-related physical debility, anxiety disorder, and depression, had a BIMS score of 14 on the quarterly MDS, indicating intact cognition. The resident reported that two pairs of pants went missing from the room and were never found, and stated the issue had been brought to multiple staff members but nothing was done and the resident remained upset about the missing clothing. Record review showed the resident filed a grievance regarding the missing pants, and the grievance documentation stated the Director of Facilities Management searched the laundry room and the contracted laundry area without locating the pants. The grievance was confirmed, and the documented corrective action was for the facility to buy new pants for the resident. During later interviews, the resident stated the facility never bought new pants or provided money to purchase them, and the Director of Facilities Management was not aware whether any pants were purchased. The Social Services staff member responsible for grievances was not aware of the grievance and had no information showing that the documented resolution was carried out.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility did not ensure that two residents reviewed for transfer and bed hold notices were provided written notification of the reason for hospital transfer and the bed hold policy, including the rate to reserve the resident’s bed. The report states that for both residents, a transfer notice and bed hold form were not located in the record, and the bed hold rate was not provided in writing to the resident and/or the resident’s representative. The facility policy required written notice at the time of transfer that specified the duration of the bed hold and the reserve bed payment policy. One resident, who had intact cognition and was his own person, was transferred to the hospital after a fall out of bed and later returned to the facility. Survey review of the medical record did not locate a bed hold notice or transfer notice for that hospitalization. Staff stated that a transfer form is sent with the resident to the hospital, but they were not aware of what happens to the form afterward or whether a copy is provided to the resident or representative. The business office manager stated the resident did not require a bed hold notice because the payer source was Medicaid and Medicaid would pay for a bed hold for 15 days. The second resident also had intact cognition and had an activated healthcare POA. This resident was hospitalized twice for low blood pressure and later for chest pain and difficulty breathing. Survey review did not locate a notice of transfer or bed hold notice for either hospitalization. Staff stated that a transfer form and bed hold notice are filled out and sent with the resident, and that the POA would be notified verbally if present, but they were not sure whether a written copy was provided. The business office manager stated that residents with Medicaid typically do not receive a bed hold agreement because the bed is held automatically for 15 days, and the nursing home administrator stated a copy should be mailed or given to the resident but needed to verify whether that was being completed.
Unassessed palm guard use not documented in care plan
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a mobility device when a left palm guard was observed in use without a documented assessment for its use and care. R5 was admitted with a diagnosis of stroke with left-sided weakness, and the admission MDS assessed limited mobility on one side of the upper and lower extremities, dependence on staff for dressing and hygiene, and cognitive impairment. During observations, R5 was seen in a wheelchair with a left palm guard on the hand in both the room and therapy area, but the device was not documented in the resident’s plan of care, CNA care list, or physician orders at the time it was first identified by surveyors. Facility staff did not have information available when asked about the device. The DON stated they would ask therapy about the palm guard and did not have any information about it. The DOR stated therapy was trialing the palm guard to decrease tone and that nursing was responsible for care planning, but the surveyor initially could not obtain a physician order or therapy assessment. A physician order and therapy recommendation were later received, both dated after surveyor inquiry, documenting use of a left palm protector for muscle weakness and to decrease risk of contractures.
Missing Catheter Care Plan and Privacy Cover
Penalty
Summary
The facility did not ensure appropriate treatment and services for a resident admitted with an indwelling catheter. The resident had diagnoses including displaced intertrochanter fracture of the left femur with surgical repair and urine retention, and the admission MDS indicated intact cognition with a BIMS score of 15. The resident was admitted with an indwelling catheter and was their own person, but survey review could not locate a baseline care plan for the resident, and the comprehensive care plan did not include an indwelling catheter care plan. Surveyors observed the resident multiple times with the catheter bag hanging from the wheelchair or bed without a privacy cover, including while being pushed in the hallway, sitting in the bedroom, lying in bed, and sitting in the dining room. The catheter bag was visible from the hallway during some observations and at one point was dragging on the floor without a protective barrier. The resident stated they usually put a cover over the catheter bag, but since being at the facility they had not had one, and they preferred to have a cover over it. The resident’s physician orders included changing the indwelling catheter and bag as needed for clinical indications and catheter care every shift. Survey review found no documentation identifying the size or type of catheter currently in use or what to use if the catheter needed replacement. Nursing staff and management acknowledged that a catheter care plan should have been initiated on admission or soon after and that a resident who wants a privacy cover should have one, but the resident’s baseline catheter care plan had not been initiated.
Oxygen administered without physician order or documentation
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured when a resident was observed receiving oxygen by nasal cannula without a physician order and without documentation of oxygen administration. The resident was admitted with acute and chronic respiratory failure, mantle cell lymphoma, and congestive heart failure, and the admission MDS assessed cognitive impairment and use of oxygen therapy. During survey observations, the resident was seen receiving oxygen at 2 LPM by nasal cannula in the room and later in the therapy room, but the medical record did not contain an order for oxygen administration and the MAR did not include oxygen administration orders or documentation. The facility policy for oxygen administration required verification of a physician's order and documentation of the rate of oxygen flow, route, and rationale. On interview, the RN reviewed the physician orders and confirmed the resident did not have oxygen administration orders, stating that oxygen use should be ordered and documented on the administration record. The RN also stated pulse oximetry was obtained every shift. At the exit meeting, surveyors shared the concern with facility leadership, and a physician order was later received authorizing oxygen at 1 to 5 liters per minute by nasal cannula to keep oxygen saturations above 90% as needed.
Pharmacy Medication Review Recommendations Not Addressed
Penalty
Summary
The facility did not ensure that monthly drug regimen review recommendations from the licensed pharmacist were acted upon for 2 of 6 residents reviewed. The facility policy required the pharmacist to report irregularities to the attending physician, Medical Director, and DON, and required non-urgent recommendations to be provided to the attending physician or designee with a response ideally within 7 days and no later than 30 days. The report also stated that if a recommendation was not addressed, the DON or designee was to be notified and the issue reviewed with the physician or designee. For one resident, R6, who was admitted with diagnoses including metabolic encephalopathy, generalized anxiety disorder, malignant neoplasms of the lower extremities, severe protein-calorie malnutrition, and insomnia, pharmacy reviews dated 8/4/2025, 10/6/2025, and 10/7/2025 contained recommendations that were not documented as addressed. The 8/4/2025 review recommended considering discontinuation of trazodone 50 mg QHS for insomnia or documenting why a gradual dose reduction was contraindicated. The 10/6/2025 review identified a PRN prochlorperazine order that was older than 14 days and lacked a valid stop date, recommending discontinuation or a valid stop date. The 10/7/2025 review repeated the same concern about trazodone. Surveyor review found no documentation that the physician acted on these recommendations or was consulted. For another resident, R1, admitted with acute and chronic respiratory failure, mantle cell lymphoma, and pneumonia, the physician orders included levofloxacin 500 mg daily for pneumonia, and the MAR showed the antibiotic was administered in 11/25, 12/25, and 1/26 without an end date. The pharmacist’s medication regimen review dated 1/5/26 noted that levofloxacin had no duration for use; the primary physician signed the recommendation on 1/22/26 and referred it to the prescribing physician, but the recommendation was not acted upon promptly. A physician assistant progress note dated 11/25/25 documented the last day of levofloxacin use as 11/26/25, yet the medication continued to be administered and the pharmacy recommendation and progress note were not followed up on.
Incomplete antibiotic and antiviral orders with missing stop dates and indications
Penalty
Summary
The facility did not ensure that residents’ drug regimens were free from unnecessary drugs because antibiotic and antiviral orders were entered without complete indications and/or stop dates. The report identified two residents, R1 and R67, whose medication orders were not fully documented as to duration and appropriate use. The facility policy titled Antibiotic Stewardship required that antibiotics be prescribed with the diagnosis/indication for use, proper dose, route, and a stop date, and that admission nurses identify the indication and duration when a resident arrives with an antibiotic already ordered. R67 was admitted with a PICC line for treatment of a right foot MRSA infection and had diagnoses including displaced intertrochanter fracture of the left femur with surgical repair, osteomyelitis of the right ankle and foot, and type 2 diabetes with foot ulcers. Survey review found R67 receiving Flagyl 500 mg PO every 12 hours with no end date and no diagnosis or indication documented for the medication, and Vancomycin 750 mg IV every 12 hours with no end date. The hospital discharge summary stated the resident had septic arthritis and osteomyelitis of the first metatarsal and proximal toes with MRSA, and that IV vancomycin and oral metronidazole were planned for a 6-week course from 1/9/2026 to 2/20/2026. Nursing staff told the surveyor that the admitting nurse was responsible for obtaining stop dates and indications, and the RN unit manager acknowledged the missing stop dates and said it was on her list to do. R1 was admitted with acute and chronic respiratory failure, mantle cell lymphoma, and pneumonia. Admission physician orders included Acyclovir 800 mg twice daily for pneumonia, Levofloxacin 500 mg daily for pneumonia, and Bactrim-DS 800-160 mg three times weekly for UTI, all without stop dates. The MARs for December 2025 and January 2026 reflected these medications, but the physician assistant note documented Levofloxacin’s end of therapy as 11/25/25 and stated Acyclovir and Bactrim-DS were prophylaxis for mantle cell lymphoma, which did not transfer to the MAR. The surveyor noted that Levofloxacin was not ended as ordered and that Acyclovir and Bactrim-DS did not have the correct indications for use and monitoring.
Failure to Maintain Accurate and Complete Daily Nurse Staffing Postings
Penalty
Summary
The deficiency involves the facility’s failure to ensure that daily nurse staffing postings were consistently displayed and accurately reflected actual staffing. Review of staffing schedules and required staff postings from 12/1/2025 through 1/20/2026 showed that 7 of 51 daily staff postings could not be located for specific dates, meaning the required information was not available on those days. Additionally, for the days where postings were available, the surveyor identified discrepancies between the posted staffing and the actual staffing schedules on two dates, specifically for the NOC shift. On those two dates, the NOC shift staff postings listed 4 CNAs, while the staffing schedules showed only 3 CNAs actually scheduled to work. During an interview, the Clinical Coordinator stated they were responsible for updating the staff postings to reflect the actual staff who worked the prior NOC shift and acknowledged that the postings for those dates should have been updated to show only 3 CNAs. The Clinical Coordinator was also unable to locate the missing staff postings and stated they should have been available. These issues affected the accuracy and availability of posted information about licensed staff directly responsible for resident care on the NOC shift for all 53 residents in the facility.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to provide evidence that an initial report of an abuse allegation was submitted to the State Survey Agency (SA) within the required two-hour timeframe for one of two residents reviewed for abuse. According to the facility's policy, all alleged violations involving abuse or serious bodily harm must be reported immediately, but not later than two hours after discovery. In this case, a resident alleged that a Certified Nurse Aide (CNA) refused to assist her to bed and was mean to her. The facility's documentation included a printed Misconduct Incident Report with the incident details, but the report was marked as a draft, and critical sections such as "Report Submitted BY" and "Report Submitted Date" were left blank. There was no documentation to confirm the actual date and time the report was submitted to the SA. During interviews, the Administrator referenced the Incident ID on the report as evidence of submission, but the absence of a submission date and time meant there was no verifiable proof that the abuse allegation was reported within the required two-hour window. The lack of proper documentation and timely reporting had the potential to delay corrective measures and appropriate responses to the abuse allegation, as required by facility policy and regulatory standards.
Incomplete Medical Record Due to Loss of Access to Contracted Provider Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who had a diabetic foot ulcer and was being followed by a contracted wound care provider. The resident was admitted with multiple diagnoses, including a right diabetic foot ulcer, and was cognitively intact during their stay. For four weeks, the resident's wound was assessed and treated by Wound MD-C, but after the facility changed its contract to a new wound care provider, it lost access to Wound MD-C's documentation. When the surveyor requested all wound assessments, the facility was only able to provide its own staff assessments and those from the new provider, Wound MD-D, but not the assessments from Wound MD-C. The Nursing Home Administrator confirmed that the facility no longer had access to Wound MD-C's records after the contract ended, resulting in an incomplete medical record for the resident.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure the safety of two residents, R1 and R2, from accidents and hazards. R1, who was admitted with diagnoses including Parkinson's Disease, Dementia, and unsteadiness on feet, experienced three falls during their stay. The facility did not complete fall risk assessments after each fall, as required by their policy, and did not implement appropriate interventions. Despite R1's severe cognitive impairment, the intervention of reminding R1 to ask for assistance was deemed inappropriate by the Director of Quality Assurance. R2, who was dependent on staff for transfers and had severe cognitive impairment, was involved in an incident where a Hoyer lift struck their lip during a transfer. The incident was not reported to the facility by the staff involved, and no immediate interventions were implemented to prevent future occurrences. The facility's Director of Nursing was unaware of the incident until informed by the surveyor, and the physician was only notified several days later. The surveyor noted that the facility's failure to conduct fall risk assessments for R1 and the lack of reporting and intervention following R2's incident were significant deficiencies. These actions and inactions contributed to the facility's inability to adequately supervise and protect residents from accidents and hazards, as required by their policies and procedures.
Inaccurate Medication Administration Records for a Resident
Penalty
Summary
The facility failed to ensure that medication administration records were complete and accurate for a resident, identified as R2, who was reviewed for medication administration. R2, who was admitted with diagnoses including Alzheimer's Disease, chronic pain, and dementia, had discrepancies in the documentation of their prescribed narcotic pain medication, Morphine. The Medication Administration Record (MAR) indicated that R2 received the medication twice in November 2024, while the facility's controlled drug log showed it was signed out six times. Further review revealed that the actual administration of Morphine was documented seven times, with multiple doses on some days not reflected in the regular MAR. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed inconsistencies in the documentation process. The LPN explained the procedure for counting narcotic medications, while the DON acknowledged that nurses sometimes entered medication administrations late, leading to discrepancies between the MAR and the narcotic medication logs. The surveyor noted that the facility did not ensure that R2's controlled medication was documented at the time of administration, resulting in inaccurate medication records.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for a resident identified as R307. R307, who was admitted with chronic peripheral venous insufficiency, lymphedema, and other conditions, developed a deep tissue injury on the left heel on 9/26/2023. However, the care plan was not revised until 9/29/2023. Subsequently, on 9/30/2023, R307 developed a suspected deep tissue injury on the right heel, but a comprehensive assessment was not completed until 10/3/2023, and the care plan was not updated accordingly. The facility's policy on pressure injury assessment and treatment was not followed, as evidenced by the lack of timely care plan revisions and comprehensive assessments. The policy requires immediate assessment and care plan updates when new skin concerns are observed, but these actions were delayed for R307. The resident's left heel injury worsened to an unstageable pressure ulcer by 10/3/2023, indicating a failure to implement effective pressure-relieving interventions and offloading techniques as recommended by the wound care specialist. Interviews with facility staff revealed gaps in communication and documentation. The Registered Nurse Unit Manager acknowledged that assessments and care plan updates should have been completed promptly, but no documentation was found for the right heel injury assessment. Additionally, there was no record of the resident refusing treatment or being informed of the risks and benefits of treatment refusal, as required by the facility's policy. These deficiencies highlight a lack of adherence to professional standards of practice in pressure ulcer care and prevention.
Dishwasher Malfunction and Maintenance Delays
Penalty
Summary
The facility failed to maintain proper working order of essential equipment, specifically two of the three dishwashing machines located in the unit kitchens. Observations revealed that these machines were leaking water onto the floor, creating a potential hazard. Additionally, one of the dishwashers did not have a functioning temperature display, which is necessary to ensure the machine reaches the required water temperature for effective sanitation. The Dietary Manager acknowledged the issues, stating that the leaking started recently and a maintenance request had been submitted. However, the temperature display issue had been ongoing for a week, and the staff relied on a disk simulator to verify the temperature, which was not demonstrated to the surveyor at the time. Further investigation showed that the Director of Facilities was only verbally informed about the leaking issue the night before or the morning of the survey. The dishwashing machines are serviced by a contracted company, and a request for service had not been formally submitted until the surveyor's inquiry. The Director of Facilities confirmed that they were waiting for a part to arrive before the contracted company could address the issue, with a service request confirmation dated two days after the initial observation. These deficiencies potentially affected all 24 residents on the two units where the dishwashers were located.
Missing DNR Forms in Resident Records
Penalty
Summary
The facility failed to ensure that advanced directives, specifically Do Not Resuscitate (DNR) forms, were present in the medical records of two residents, R6 and R19, as required by their policy. R6, who has a range of medical conditions including heart failure and dementia, was admitted with a moderately impaired cognitive status and an activated power of attorney for medical decisions. Upon review, the surveyor found that R6's DNR form was missing from the medical record, and the facility staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), were unable to locate it. They acknowledged the absence and were in the process of obtaining a new signed form. Similarly, R19, who is cognitively intact and has an activated power of attorney, also did not have a DNR form in their medical record upon review. Despite the facility's policy requiring the DNR form to be signed and placed in the resident's medical record upon admission, the form was not found. The NHA and DON were again unable to explain the absence of the form and were working to rectify the situation. The surveyor noted these deficiencies and shared concerns with the facility's administration.
Failure to Ensure Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at the time of their choosing. The deficiency involved a resident with severe cognitive deficits and an activated Power of Attorney for Health Care. The facility restricted the resident's family member to supervised visitation following an incident where the family member allegedly verbally and physically abused the resident. However, the facility did not develop strategies to ensure safe and enjoyable visits, nor did it provide supervision for weekend visits, effectively limiting the family member's access to the resident. The facility's administration did not meet with the family member to discuss the imposed visitation arrangements, and there was no documentation of any plan to change the visitation restrictions. The social worker did not document interactions with the resident regarding the restricted visitation or assess the potential impact on the resident. Additionally, the family member was not informed of the requirements for supervised visitation and was turned away when attempting to visit without an appointment. The facility's policy stated 24-hour access for visitors, which was not upheld in this case.
Neglect in Resident Transfer Using Hoyer Lift
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a Hoyer lift transfer. The resident, who has a history of cerebral infarction resulting in left side hemiplegia, dysphagia, and other conditions, was transferred by a single staff member using a Hoyer lift, contrary to the care plan that required two staff members for such transfers. This resulted in a bruise on the resident's right forearm. The facility's policy on mechanical lifts mandates the use of such equipment according to current standards and guidelines, which were not followed in this instance. The incident was documented in the facility's progress notes, and the resident was noted to have a bruise that increased in size over time. The resident was on medications that increased the risk of bleeding, which may have contributed to the severity of the bruise. During interviews, the resident could not recall the specifics of the transfer or how the bruise occurred, and the staff member involved was no longer employed at the facility. The facility's investigation concluded that the bruise was a result of the improper transfer by a single staff member, which was a deviation from the resident's care plan.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to report three allegations of abuse and neglect involving a resident, identified as R36, within the required timeframe to the Nursing Home Administrator (NHA) and the State Agency. The incidents included verbal and physical abuse by the resident's family member, as well as an allegation of neglect. The verbal abuse incident was observed on August 11, 2024, but was not reported to the NHA until August 15, 2024, and subsequently to the State Agency on August 16, 2024. The physical abuse, which occurred on August 10 and 11, 2024, was not reported to the NHA until August 17, 2024, and was only reported to the State Agency on September 18, 2024, during the survey. The facility's policy on abuse prevention requires immediate reporting of such incidents, but this was not adhered to. Staff members, including a Registered Nurse (RN) and Certified Nursing Assistants (CNAs), witnessed the abuse but failed to report it promptly. The RN heard the family member verbally abusing the resident and was informed of physical contact by CNAs, yet did not report these observations immediately. Similarly, the CNAs who witnessed the abuse did not inform the facility administration until days later, during an investigation of the verbal abuse allegation. Additionally, an allegation of neglect was reported to an RN on June 2, 2024, regarding the resident being left in a wheelchair for 40 hours continuously. This allegation was not reported to the NHA or the State Agency, as the RN dismissed it as implausible. The facility's policy mandates reporting neglect within specified timeframes, but this was not followed. The failure to report these incidents promptly and in accordance with policy was identified during the survey, highlighting deficiencies in the facility's handling of abuse and neglect allegations.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into three allegations of abuse and neglect involving a resident, identified as R36. The first incident involved an allegation of verbal abuse by R36's daughter, which was reported to have occurred on August 11, 2024. Despite being informed of the incident, the facility's investigation was incomplete as it did not involve a comprehensive discussion with the family to understand the context of the alleged abuse, nor did it address the family dynamics or the resident's cognitive impairments. Additionally, the facility did not adequately communicate the reasons for implementing supervised visits with the family. The second incident involved an allegation of physical abuse by R36's daughter, which emerged during the investigation of the verbal abuse incident. The facility administration was made aware of these allegations on August 17, 2024, but failed to initiate an investigation until September 17, 2024. This delay in response indicates a lack of adherence to the facility's policy on timely investigation and reporting of abuse allegations. The third incident involved an allegation of neglect, where it was claimed that R36 was left in a wheelchair for 40 continuous hours. This allegation was documented by RN-G on June 2, 2024, but was not reported to the Nursing Home Administrator or the Director of Nursing for investigation. RN-G dismissed the claim as implausible and did not document conversations with other staff regarding the incident. This oversight resulted in a failure to investigate a potential neglect situation, as required by the facility's policies.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services to a resident, identified as R36, to help them achieve the highest possible quality of life. R36, who has severe cognitive deficits due to Alzheimer's Disease, was subjected to restricted visitation with a family member following an incident where the family member allegedly verbally and physically abused R36. The facility instituted supervised visitation by appointment only, but did not assess or monitor the impact of this decision on R36's well-being. Additionally, there was no documentation of meetings with R36's family or Power of Attorney for Healthcare to discuss future visitation arrangements. The facility's social worker did not document interactions with R36 regarding the visitation restrictions or assess the potential impact on R36's mental health. The care plan for R36 was not updated to reflect the changes in visitation, and the family member reported being uninformed about the requirements for supervised visits. The facility's policy on social services emphasizes maintaining contact with family members and identifying social and emotional needs, but these were not adhered to in R36's case. The deficiency was noted during a survey, and no additional information was provided by the facility to explain the lack of assessment and monitoring of R36's mental well-being after the visitation restrictions were implemented.
Failure to Promptly Resolve Resident Grievances
Penalty
Summary
The facility did not make a prompt effort to resolve grievances for four residents. One resident voiced concerns about not being dressed or getting out of bed until the second shift and not receiving a shower. The facility did not follow up with the resident to ensure there were no further concerns and did not document the date the written decision was issued. Another resident had similar concerns about not being dressed until the second shift, and the facility failed to include a summary of findings or a conclusion in the grievance documentation. Additionally, the facility did not follow up with this resident to see if there were any further concerns and did not document the date a written decision was issued. A representative for another resident filed a grievance about the resident not receiving a shower, being soaked, and needing a new pad. The grievance documentation lacked a summary of findings or conclusions, confirmation of receipt, follow-up with the representative, and the date the written decision was issued. Similarly, a friend of another resident filed a grievance about the resident not receiving a shower, and the documentation did not include the date a written decision was issued. The facility's grievance policy requires documentation of the date the grievance was received, a summary of the grievance, steps taken to investigate, findings or conclusions, confirmation of the grievance, corrective actions, and the date the written decision was issued. The policy also mandates acknowledging the grievance within seven working days and issuing a final written decision within 30 days. The facility failed to adhere to these requirements, as evidenced by the incomplete and inconsistent documentation of the grievances reviewed by the surveyor.
Failure to Provide Consistent Showering Assistance
Penalty
Summary
The facility did not ensure that a resident received the required assistance with their activities of daily living (ADLs), specifically in relation to showering and bathing. The resident, who was admitted with diagnoses including Parkinson's Disease, status post left hip fracture, chronic kidney disease (CKD), and chronic lymphocytic leukemia (CLL), was assessed as requiring substantial assistance for showering. Despite this, the resident's care plan, which indicated a preference for showers and the need for extensive assistance with two-person staff support, was not consistently followed. Documentation revealed that the resident only received one shower during the weeks of 1/7/24 to 1/13/24 and 1/21/24 to 1/27/24, and no showers during the week of 1/28/24 to 2/3/24. Additionally, there were multiple instances where the daily charting by CNAs was either blank or indicated that the resident did not receive a shower or bath. Interviews with facility staff, including an LPN, CNA, DON, OTA, and RN Unit Manager, revealed a lack of recollection or awareness regarding the resident's showering schedule and needs. The CNA confirmed that they document when a shower is provided, but the records did not reflect consistent care. The DON and other staff members were unable to provide additional information or recall specific details about the resident's showering routine. This lack of documentation and follow-through on the resident's care plan led to the identified deficiency in providing necessary assistance with ADLs.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility did not ensure that a resident received needed care and services based on professional standards of practice. Specifically, the facility failed to obtain weekly weights for a resident (R2) who was at risk for weight loss and had a physician's order for weekly weights. This failure occurred over a period of eleven weeks, during which the resident's weight was not recorded as required by the physician's order. The facility's weight monitoring policy, last reviewed in January 2023, mandates weekly weights for the first four weeks and monthly thereafter, but this was not adhered to in R2's case. R2 was admitted with multiple diagnoses, including Hemiplegia following a stroke, Diabetes Mellitus Type II, Dysphagia, and Obesity. The resident's admission weight was 186 lbs, and by the last recorded weight, it had dropped to 131.6 lbs. Despite the significant weight loss, the facility did not document weekly weights on several specified dates. Interviews with the Certified Dietician Manager and the Director of Nursing confirmed that the physician's order for weekly weights should have been followed, but no additional information was provided to explain the lapses in weight monitoring.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
