Avina Of Fond Du Lac
Inspection history, citations, penalties and survey trends for this long-term care facility in Fond Du Lac, Wisconsin.
- Location
- 115 E Arndt St, Fond Du Lac, Wisconsin 54935
- CMS Provider Number
- 525270
- Inspections on file
- 29
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Avina Of Fond Du Lac during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment on the 100 wing, where multiple ceiling tiles and walls near the dining area, nurses’ station, nourishment room, and common area showed black/green and brown fuzzy growth and water damage. A leaking ice machine in the nourishment room, reportedly present for an extended period and struck by a resident’s motorized wheelchair, was described by staff as the source of mold that spread to adjacent walls, ceiling tiles, and a nearby bathroom. The MD acknowledged long-standing leaks and water damage from the ice machine, a prior pipe burst, and a leaky HVAC unit but had not arranged repairs, and the NHA and DON were unaware of the extent of the staining and damage. A resident with mild intermittent asthma, migraines, and anxiety, and intact cognition, reported visible mold on ceiling tiles and other areas and believed the mold in common areas affected the resident’s asthma.
A resident with intact cognition and diagnoses including polycystic ovarian syndrome and asymptomatic premature menopause had an order for an Estradiol transdermal patch to be applied twice weekly. On one scheduled administration date, the Estradiol patch was not given because an LPN could not find it on the medication cart and did not seek assistance from other staff or contact the pharmacy. The MAR reflected a code indicating "other/see progress note," but no progress note documented administration, omission, or provider notification. The resident reported not receiving the patch because staff could not locate it and stated having pain when the patch was not on, while the DON later confirmed staff are expected to locate missing medications, contact the pharmacy, document omissions, and notify the provider.
A resident with dementia, severe cognitive impairment, and an activated POA experienced a physical and verbal altercation with another resident and later displayed repeated physical aggression toward staff, including inappropriate grabbing. Despite these documented behaviors and a facility policy requiring care plan review and revision upon status change, the resident’s care plan initially lacked any mention of aggression or sexually inappropriate behavior. When surveyors reviewed the record, the electronic care plan history showed that aggression-related problems and interventions were only added later, while paper copies inaccurately reflected earlier creation dates, demonstrating that the care plan was not updated in a timely or accurate manner after the incidents.
A resident with severe cognitive impairment and multiple serious diagnoses had a POAHC document on file, but the POAHC was never activated and the resident remained their own decision maker. Despite this, the designated POAHC agent signed vaccination consent and declination forms, DNR paperwork, admission documents, and a hospice agreement on the resident’s behalf. Facility staff confirmed there was no documentation that the resident authorized this individual to sign for them, resulting in healthcare decisions being made without documented consent from the resident or an activated POAHC.
A resident with schizophrenia and intact cognition reported for over a month that the bathroom faucet in the resident’s room did not work properly, yet it was not repaired in a timely manner. The facility’s policy required immediate reporting and documentation of maintenance issues, but the MD stated there were no work orders for the room and that work orders are discarded after completion. A housekeeper reported having written up the faucet concern about six weeks earlier and turning it in, assuming repairs were done. The NHA confirmed multiple accepted methods for notifying the MD of needed repairs and acknowledged the faucet should have been fixed promptly.
Two residents received each other’s medications when a medication technician failed to follow the six rights of medication administration and relied on inaccurate room identification. Both residents, who had multiple serious diagnoses and cognitive impairment, lacked photos in the electronic record, and the name plaques outside their rooms were incorrect following a room change that was not properly updated. Medication occurrence reports documented that each resident was given the other’s prescribed morning medications, and neither resident’s medical record contained a progress note about the medication error.
The facility failed to maintain sanitary conditions in dishwashing and food preparation, affecting all residents. Staff did not test the sanitizing solution correctly, and the cook did not follow proper hand hygiene while preparing food. The Dietary Manager confirmed the need for accurate testing of sanitizer concentration and proper handwashing practices.
The facility restricted two residents from using electric wheelchairs or scooters indoors following a policy change, impacting their quality of life and independence. Both residents, with intact cognition and various medical conditions, expressed distress over the inability to use their mobility aids, which affected their participation in activities and daily routines. The policy was changed to prevent potential hazards, but it was not communicated effectively to the residents, leading to feelings of anger and depression.
The facility did not ensure an RN was on duty for 8 consecutive hours daily, 7 days a week, affecting all 46 residents. Staffing schedules showed RN absence on 24 of 26 reviewed days, with reliance on LPNs and on-call DON/ADON. Staff interviews confirmed inconsistent RN presence, with recent hiring of an RN for alternate weekends and on-call arrangements for others.
The facility failed to store and prepare food in a sanitary manner, affecting all residents. During an inspection, it was found that time/temperature control foods were not labeled with open or use-by dates, violating the Wisconsin Food Code. Various food items in dry storage, the walk-in cooler, and the freezer were unlabeled, undated, or expired. The Dietary Manager acknowledged the issue and the lack of a reference sheet for safely storing food items.
A resident was transferred to the hospital twice without receiving the required written transfer notices, which should have included the date, reason, location, and appeal rights. Despite having intact cognition, the resident did not recall receiving these notices. The facility's policy requires such notices, but the Director of Nursing and Nursing Home Administrator confirmed that the correct forms were not provided.
The facility failed to complete neurological checks as per policy for two residents who experienced falls. One resident, with a history of restlessness and a femur fracture, had multiple unwitnessed falls with missing or incomplete neurochecks. Another resident, with a history of stroke and hemiplegia, also had missing neurochecks after a fall. Staff interviews confirmed the lapses in completing required assessments.
The facility failed to report allegations of sexual abuse and neglect involving two residents to the State Agency, local law enforcement, and the residents' legal representatives. The administration did not follow the facility's abuse prevention policy, resulting in unreported incidents and inadequate investigation.
The facility failed to thoroughly investigate allegations of abuse and neglect for three residents. One resident with dementia inappropriately touched another resident twice, but only one incident was reported to the State Agency, and no new interventions were implemented. Another resident with a history of trauma was not assessed for consent, and the facility did not consider their history in their response. Additionally, an allegation of neglect for a resident receiving hospice care was not investigated.
Failure to Maintain Clean, Mold-Free Environment on 100 Wing
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on the 100 wing, where multiple areas showed visible mold-like, black/green, and brown fuzzy growth on walls and ceiling tiles. During an environmental tour, a ceiling tile outside the main dining area on the 100 wing was observed with two black fuzzy spots surrounded by a dark gray stain. Ceiling tiles behind the 100 wing nurses’ station contained multiple black fuzzy stains spanning the corners of four tiles, connecting in the middle and spreading across the tiles. A ceiling tile with a sprinkler head at the entrance to the 100 wing common area/living room was observed to be warped, not fitting correctly in the ceiling grid, and covered with a brown fuzzy stain. Surveyors also observed structural damage and suspected mold growth on and behind walls near the nourishment room and nurses’ station. Underneath the nurses’ station, on a wall that shared a boundary with the nourishment room, there was a black/green fuzzy stain approximately 6 inches by 4 inches, with the wall appearing bubbled. The baseboard connecting the wall and the nurses’ station was falling off, exposing drywall with black fuzzy stains. A Medication Technician reported that there had been mold in the nourishment room due to a leaking ice machine, and that the mold had spread over the walls of the room, to ceiling tiles above and behind the nurses’ station, and to a bathroom behind the nurses’ station. The Medication Technician stated these concerns had been present since the technician started at the facility approximately two years earlier and that the ice maker had been taken out of use because the ice appeared to have mold. The Maintenance Director acknowledged that the ice machine in the nourishment room had leaked for some time before discovery, damaging walls in the nourishment room and spreading to bathroom walls behind the nourishment room and nurses’ station, and also stated that a resident had run into the ice machine with a motorized wheelchair approximately six months earlier. The Maintenance Director attributed some ceiling tile staining to a pipe burst about two years earlier and to a leaky HVAC system on the roof but had not contacted anyone for roof or HVAC repairs and stated not paying attention to ceiling tiles. The Nursing Home Administrator and DON were not aware of the black/green fuzzy stains on ceiling tiles, the leaky HVAC system, or the incident in which a resident ran into the ice maker. A resident with diagnoses including mild intermittent asthma, migraine with aura, and anxiety disorder, and an intact BIMS score, reported that there was mold on ceiling tiles and in other areas such as bathrooms and walls, and felt that mold in common areas affected the resident’s asthma.
Failure to Administer Ordered Estradiol Patch and Document Omission
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services to ensure accurate administration of drugs and biologicals for one resident. The facility’s Medication Administration policy, revised January 2026, requires staff to keep the medication cart clean, organized, and adequately stocked, to administer medications according to physician orders, and to correct discrepancies and report them to the nurse manager. The resident was admitted with diagnoses including conversion disorder with motor symptom deficit, polycystic ovarian syndrome, asymptomatic premature menopause, and dysmenorrhea, and had a BIMS score of 14/15 indicating intact cognition. The resident had a physician’s order for an Estradiol transdermal patch 0.025 mg/24 hr to be applied twice weekly on Mondays and Fridays for hormone therapy. On the date in question, the Medication Administration Record showed a code of “10” (Other/See progress note) for the Estradiol dose, but there was no corresponding progress note documenting administration, omission, or provider notification. The resident reported not receiving the Estradiol patch a few weeks prior because staff could not find it and stated experiencing pain when the patch was not on. The LPN responsible for medication administration on that date confirmed not administering the Estradiol patch because it could not be located and acknowledged not entering a progress note or notifying the provider. The LPN also stated that staff are expected to call the pharmacy or ask another staff member if a medication is missing, and the DON confirmed that staff are expected to locate the medication or call the pharmacy and document in the record if an ordered medication is not given and to update the provider.
Failure to Timely Update Care Plan After Aggressive and Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan in a timely manner following significant behavioral incidents, including a resident-to-resident altercation and subsequent physical aggression toward staff. The facility’s policy required the comprehensive care plan to be reviewed and revised as necessary when a resident experienced a status change. The resident, who had dementia, a UTI, altered mental status, a BIMS score of 3/15 indicating severe cognitive impairment, and an activated POA for healthcare, was involved in a physical and verbal altercation with another resident. Following this incident, the resident was placed on 15‑minute checks and moved to a different unit, but the care plan in the electronic medical record did not reflect a history of physical and verbal aggression toward residents and staff. Progress notes documented that the resident was physically aggressive with staff, including an incident where the resident punched, grabbed, and twisted a staff member’s breast, laughed, and refused to let go, as well as multiple other notes of physical aggression toward staff. When the surveyor reviewed the care plan in the electronic record, it lacked any mention of the resident’s aggression or inappropriate grabbing of staff. Paper copies later provided by the NHA showed care plans and interventions all dated as created on the date of the initial incident, including new entries describing confusion, episodes of physical aggression, and interventions such as redirection, 1:1 activities, and contacting the spouse during high agitation. However, the electronic record’s history showed that these aggression-related care plan elements and interventions were actually created and updated on a later survey date, revealing a discrepancy between the electronic care plan history and the dates printed on the paper copies.
Failure to Uphold Resident’s Healthcare Decision-Making Rights
Penalty
Summary
The facility failed to ensure a resident’s right to make healthcare decisions was upheld when the resident’s Power of Attorney for Healthcare (POAHC) had not been activated, yet the designated POAHC agent signed multiple medical and admission documents. The resident was admitted with diagnoses including encounter for palliative care, severe protein calorie malnutrition, malignant neoplasm of the bladder, and type 2 diabetes, and had a BIMS score of 6/15 indicating severely impaired cognition. The medical record contained a POAHC document listing the POAHC-F as the number 2 agent, but the resident had not been deemed incapacitated upon admission and remained their own decision maker throughout the stay. Despite this, the record showed that POAHC-F signed an influenza vaccination consent, a COVID-19 vaccination declination, Do Not Resuscitate (DNR) paperwork, and admission paperwork. During interviews, the Social Worker confirmed that the POAHC was never activated during the resident’s stay and acknowledged that there was only discussion of activating it prior to the resident’s death. The Social Worker stated that the resident had difficulty signing documents, so POAHC-F signed on the resident’s behalf. The Nursing Home Administrator also confirmed that the POAHC was not activated while the resident was in the facility and that POAHC-F signed a hospice agreement for the resident. Both staff members confirmed that the facility lacked documentation showing that the resident had agreed to allow POAHC-F to sign documents on their behalf, resulting in the resident’s healthcare decisions being executed without documented consent or an activated POAHC.
Failure to Timely Repair Malfunctioning Bathroom Faucet
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment by not timely repairing a malfunctioning bathroom faucet for one resident. The resident, who had schizophrenia but intact cognition with a BIMS score of 15/15, reported that the faucet in the resident’s bathroom did not work well and stated having informed multiple staff members over the course of a month or longer. When the surveyor tested the faucet, only a light trickle of water was observed. The facility’s policy on Reporting Maintenance Issues required that all maintenance issues impacting resident safety, clinical care, infection prevention, dignity, or facility operations be reported immediately using the approved process and that all issues be documented with specific details and retained per policy. Despite this policy, the Maintenance Director reported there were no work orders for the resident’s room and stated that staff typically call, text, or speak in person to request repairs, and that work orders are thrown away after completion. The Maintenance Director was not aware of the faucet problem until accompanying the surveyor to the room and observing the issue. A housekeeper reported being aware that the faucet did not work well and stated having written down the concern and turned it in approximately a month and a half earlier, believing that repairs were completed timely. The Nursing Home Administrator confirmed that staff could notify the Maintenance Director of needed repairs by calling, texting, discussing in morning meetings, or filling out a work order, and verified that the resident’s faucet should have been repaired in a timely manner.
Medication Errors Due to Failure to Verify Resident Identity and Inaccurate Room Identification
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate administration of medications for two residents when a medication technician administered each resident the other’s medications. On the morning of 9/11/25, MT-G gave one resident a set of medications that included furosemide 40 mg, potassium ER 10 mEq, donepezil 25 mg, metoprolol ER 50 mg, sertraline 50 mg, memantine 5 mg, and ursodiol 300 mg instead of the resident’s prescribed allopurinol 100 mg, amlodipine 2.5 mg, multivitamin, cyanocobalamin 1000 mcg, and isosorbide mononitrate ER 30 mg. This resident had been admitted earlier that month with diagnoses including malignant neoplasm of the bladder, infection and inflammatory reaction due to an indwelling urethral catheter, and was receiving palliative care, with a BIMS score of 6 indicating severely impaired cognition. The resident’s medication occurrence report documented that the wrong medications were administered and that the resident did not have a picture in the facility’s medical record system, and the medical record lacked a progress note regarding the medication error. The second resident, admitted with diagnoses including acute osteomyelitis of the left ankle and foot, aneurysm of the ascending aorta, cerebral infarction, and transient ischemic attack, with a BIMS score of 11 indicating moderately impaired cognition, was administered the first resident’s medications on the same morning. The medication occurrence report for this resident also documented that the wrong medications were given and that the resident did not have a picture in the medical record system, and the medical record similarly lacked a progress note regarding the medication error. The Nursing Home Administrator confirmed that the two residents received each other’s morning medications, that MT-G did not complete the six rights of medication administration, and that the name plaques outside both residents’ doors were incorrect due to a room change and failure to update the plaques. The Administrator also confirmed there was no education provided regarding the accuracy of residents’ name plaques or the importance of entering residents’ pictures into the medical record system upon admission.
Sanitation and Food Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that dishes were washed and food was prepared in a safe and sanitary manner, potentially affecting all 46 residents. The deficiency was identified through observations, staff interviews, and record reviews. The facility's policy required dishes and cookware to be cleaned and sanitized after each meal, with the sanitizing solution tested using a test strip to ensure appropriate levels. However, the cook (CK-C) did not test the water temperature before testing the sanitizing solution, which is necessary to obtain an accurate result. Additionally, the Dietary Aide (DA-D and DA-E) did not know how to test the concentration of the sanitizer, despite it being part of their job duties. Further observations revealed that CK-C did not follow proper hand hygiene practices while preparing pureed fish. CK-C touched the lid of a garbage bin and did not wash hands before continuing food preparation. CK-C also handled food with bare hands and did not wash hands between handling dirty dishes and preparing lunch. The Dietary Manager (DM-G) confirmed that cooks are responsible for checking the sanitizer concentration and that the dishwater should be between 65 and 75 degrees Fahrenheit when tested. The failure to adhere to these procedures compromised the sanitary conditions of food preparation and dishwashing in the facility.
Facility Policy Change Restricts Residents' Use of Mobility Aids
Penalty
Summary
The facility failed to honor the rights of two residents, R10 and R11, by not allowing them to continue using their electric wheelchairs or motorized scooters inside the facility. This decision was made following a change in the facility's policy, which prohibited the use of motorized mobility aids indoors, citing potential hazards to other residents. The Nursing Home Administrator (NHA-A) confirmed that the policy change was communicated to the residents and their legal representatives, but the residents were not provided with a copy of the new policy. Both residents had intact cognition and made their own medical decisions, as indicated by their Minimum Data Set (MDS) assessments. R10, who had multiple diagnoses including dementia and difficulty in walking, expressed feelings of mild anger and depression due to the policy change, as it made it difficult for R10 to self-propel a manual wheelchair. R11, who also had several medical conditions, was devastated by the inability to use a scooter, which affected R11's independence and participation in activities. R11 reported that without the scooter, R11 could not attend activities or eat in the dining room comfortably, as the CNAs were too busy to assist. The NHA-A stated that the policy was implemented to prevent potential hazards, but this decision negatively impacted the residents' quality of life and their ability to exercise self-determination and communication rights.
Failure to Maintain RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified during a review of nurse staffing schedules and Payroll Based Journal (PBJ) records, which revealed that the facility did not have an RN on duty for 8 consecutive hours on 24 out of 26 days reviewed. The absence of RN coverage was particularly noted on weekends and holidays, with the facility relying on Licensed Practical Nurses (LPNs) and having the Director of Nursing (DON) or Assistant Director of Nursing (ADON) on-call instead of physically present. Interviews with staff, including LPNs and the DON, confirmed that the facility had recently hired an RN to work every other weekend, while the DON or ADON were on-call on the opposite weekends. However, the DON acknowledged that on some days, the DON was in the building but primarily engaged in office work rather than providing direct care. The DON also mentioned a belief that the facility had a waiver for RN staffing, which was not confirmed by the Nursing Home Administrator. The lack of consistent RN presence had the potential to affect all 46 residents in the facility.
Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 46 residents residing in the facility. During an inspection, it was observed that the facility did not label time/temperature control foods with open or use-by dates, as required by the Wisconsin Food Code 2020. The Dietary Manager (DM) confirmed that the facility follows this code as their standard of practice. During a tour of the kitchen, several items in dry storage, the walk-in cooler, and the freezer were found to be unlabeled, undated, or expired. These included loaves of bread, hamburger buns, marshmallows, chocolate chips, mashed potatoes, pudding, breadcrumbs, hashbrowns, sugar, flour, cereals, shredded cheese, mayonnaise, chicken noodle, hard-boiled eggs, sliced cheese, mozzarella cheese, pinto beans, meatballs, chicken fried steak, meat sauce, pulled pork, spice cake, and diced pork. Additionally, various sandwiches and snacks for residents in the first and second-floor unit refrigerators/freezers were also without use-by dates. The DM acknowledged that the facility uses a first in/first out (FIFO) food storage process and that staff should date items with the date they were opened or made and a use-by date. However, the DM admitted to not having a reference sheet for safely storing food items and was informed by the facility's contracted kitchen company that the current dating system was insufficient. Despite being aware of the issue, the DM had not yet found a food storage guideline to share with the kitchen staff.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide a resident, identified as R8, with the required written transfer notices during two hospitalizations. R8 was transferred to the hospital on two occasions due to chest pain and shortness of breath, but did not receive written notices that included the date of transfer, reason for transfer, location of transfer, and appeal rights. The facility's policy mandates that such notices be provided prior to any transfer or discharge, but this was not adhered to in R8's case. R8, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, did not recall receiving any written transfer notices. The Director of Nursing confirmed that the medical record contained eInteract transfer forms, which are not the correct forms for notifying residents of transfers. The Nursing Home Administrator also acknowledged that the proper transfer notices were not provided to R8, confirming the deficiency in following the facility's policy.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed according to policy for two residents who experienced falls. Resident 35, who had diagnoses including restlessness, agitation, a fracture of the left femur, and diabetes, experienced multiple unwitnessed falls on four separate occasions. Despite having intact cognition, as indicated by a BIMS score of 14 out of 15, the resident's neurochecks were incomplete or missing on each occasion. Specifically, there were four missing neurochecks on one date, two incomplete checks on another, one missing check on a third date, and six missing checks on the last recorded fall. Similarly, Resident 38, who had a history of stroke and flaccid hemiplegia affecting the left side, experienced an unwitnessed fall. This resident, with moderately impaired cognition as indicated by a BIMS score of 12 out of 15, also had five missing neurochecks following the fall. The facility's policy required neurochecks to be completed at specific intervals following a fall, but these were not adhered to. Interviews with staff, including an LPN and the DON, confirmed the missing neurochecks and the expectation that all checks should be completed as per policy.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act for two residents. Specifically, the facility did not report an allegation of sexual abuse involving two residents to the State Agency, local law enforcement, or the residents' legal representatives. The incident involved one resident inappropriately touching another resident on two separate occasions. Despite the facility's policy requiring immediate reporting of such incidents, the administration did not report the second incident, believing it was not necessary because the affected resident did not want to get the perpetrator in trouble. Additionally, the facility did not report an allegation of neglect involving another resident to the State Agency. The resident, who had multiple diagnoses including cancer and dementia, was receiving hospice services and passed away shortly after the incident. The resident's Power of Attorney accused the facility of neglect, stating that the resident was not receiving adequate care and was left to die without proper assistance. The Director of Nursing confirmed that the allegation was not reported to the State Agency. These failures indicate a significant lapse in the facility's adherence to its own abuse prevention policy and regulatory requirements. The incidents were not reported as required, and the administration did not take appropriate action to ensure that all allegations of abuse and neglect were properly investigated and reported to the necessary authorities.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure allegations of abuse and neglect were thoroughly investigated for three residents. Resident 3, who had dementia and moderately impaired cognition, was involved in two incidents of inappropriate sexual contact with Resident 2. Despite the incidents being reported to administration, only one was reported to the State Agency, and no thorough investigation or new interventions were implemented to ensure resident safety. The facility's Director of Nursing and Nursing Home Administrator confirmed that the allegation of abuse was not thoroughly investigated, and staff training on 1:1 duties was not reinforced after the incidents. Resident 2, who had a history of traumatic brain injury and previous trauma, was inappropriately touched by Resident 3 on two occasions. The facility did not assess Resident 2's ability to consent to sexual touch, nor did they consider Resident 2's history of abuse and trauma in their response. The facility's response was limited to staff education on 1:1 job duties, which did not prevent the abuse from occurring again. Resident 1, who had colon and liver cancer and moderately impaired cognition, was receiving hospice services and passed away. The resident's Power of Attorney alleged neglect, stating that the resident was not receiving adequate care. The Director of Nursing confirmed that the facility did not investigate the allegation of neglect made by Resident 1's Power of Attorney.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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