Avina Of Kenosha
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenosha, Wisconsin.
- Location
- 3100 Washington Rd., Kenosha, Wisconsin 53144
- CMS Provider Number
- 525179
- Inspections on file
- 33
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Avina Of Kenosha during CMS and state inspections, most recent first.
A cognitively intact resident with cancer metastatic to bone and a history of stroke developed a new stage 3 pressure ulcer on the left heel, documented with specific measurements and sanguineous drainage, and wound care orders were initiated. However, there was no documentation that any family member was informed of this significant change in condition, and a family member later reported not being notified of the wound. An RN stated the resident had not specified whether family should be notified and had no designated representative, and also acknowledged there was no EMR documentation that the resident was asked about or declined family notification, despite facility policy requiring notification of a designated family member for significant health status changes in competent residents.
A resident with severe cognitive impairment and a high risk for falls experienced a fall after sliding out of a wheelchair when a required non-slip Dycem material was not in place, despite this intervention being documented in the care plan and CNA Kardex. The absence of Dycem was confirmed by both the CNA and unit manager, and the facility's investigation identified this omission as the root cause of the fall.
Surveyors found that kitchen staff did not consistently use proper hair restraints or follow sanitary food handling procedures, including failing to restrain facial hair and not cleaning thermometer probes between foods. These actions occurred during meal preparation and service, potentially affecting all residents receiving meals from the main kitchen.
The facility submitted inaccurate PBJ staffing data to CMS for a quarter, resulting in a trigger for low weekend staffing, despite internal schedules showing no gaps. Interviews with the scheduler and DOR indicated no staffing concerns and no use of agency staff, but the DOR did not investigate system alerts about low staffing, and the NHA was unaware of any issues.
Several admission and annual MDS assessments were not completed within the required timeframes due to staffing shortages in the MDS coordinator team. An LPN responsible for MDS assessments was on extended medical leave, and although some support was provided by coordinators from other facilities, the coverage was insufficient, resulting in multiple late or incomplete assessments.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period after assessment, as evidenced by a review of assessment records and transmission logs.
A cook prepared pureed cornbread for several residents on a pureed diet without following the facility's standardized recipe, using unmeasured ingredients and resulting in an incorrect food consistency. The Dietary Manager confirmed that recipes are required for all pureed foods and that the cook did not adhere to this policy.
A resident with multiple medical conditions reported concerns about not consistently receiving double meal portions as requested. The concern was communicated to a CNA Scheduler, but no grievance form was completed, and the issue was only addressed verbally with the Dietary Manager. The resident's care plan and meal tickets did not reflect the request, and the grievance was not documented or formally resolved according to facility policy.
A resident’s quarterly MDS assessment was not completed within the required timeframe due to staffing shortages in the MDS coordinator team. The full-time LPN responsible for assessments was on medical leave, and although assistance was provided by coordinators from other facilities, the coverage was insufficient, resulting in a late assessment.
Two residents did not have their care plans revised or care conferences completed as required. One resident's care plan lacked focus areas for hearing deficit and depression, despite documented needs, and was not updated until well after admission. Another resident did not have a care conference scheduled after a quarterly MDS assessment and was unaware of the process. Staff interviews confirmed delays and omissions in care planning and conference scheduling.
A resident's privacy was compromised due to a faulty door that did not stay closed, an issue persisting since September. The resident, who was cognitively intact and admitted with osteoarthritis, used a towel and pillowcase to keep the door shut, as suggested by a CNA. The Administrator acknowledged the problem, attributing it to weather-related issues, but the Unit Manager/RN was unaware of the door's condition, indicating a lack of communication regarding maintenance work orders.
A facility failed to document and potentially administer insulin and a fingerstick blood sugar test (FSBS) for a resident with type one diabetes. The resident's Medication Administration Record (MAR) showed missing entries for insulin administration and FSBS on two occasions. The Director of Nursing confirmed that the responsible nurse forgot to document due to being busy, but it was unclear if the insulin or FSBS was administered, placing the resident at risk for serious medical consequences.
Two residents' MAR and TAR were incomplete, failing to document medication and wound care treatments. Despite administration, nurses did not record these due to being busy or forgetting, as confirmed by the DON.
The facility did not follow the prescribed menu for all resident diets, affecting 81 residents. Observations revealed discrepancies in portion sizes served compared to the menu specifications. Residents on regular and mechanical soft diets received less Chicken Cacciatore and carrots than prescribed, while those on puree diets received less puree chicken. The Dietary Manager confirmed the menu was not followed, and residents reported insufficient food during meals.
The facility failed to maintain safe water temperatures, with readings ranging from 81 to 139 degrees Fahrenheit, affecting 36 residents. The Maintenance Employee checked temperatures at hot water tanks weekly but did not consistently monitor or document temperatures in resident rooms. The Administrator and Regional Nurse Consultants were unaware of a water temperature policy, and monitoring logs did not include resident bathrooms or shower rooms.
The facility failed to maintain a functioning call system with auditory alarms in the North station, affecting 22 residents. The call light panel did not work, and staff were unaware of how long it had been non-functional. Observations confirmed that while call lights over room doors were operational, the panel at the nurse's station neither lit up nor made noise. The issue persisted for about a month without a formal work order being submitted, despite being reported verbally.
A resident with COPD was not provided with a physician's order for oxygen therapy, despite being tried on oxygen due to low oxygen saturations. The resident's care plan did not include oxygen therapy, and the deficiency was noted when the resident was sent to the hospital for low oxygen saturation. The DON acknowledged that the oxygen order was not processed.
A resident was at risk due to improper medication administration via a g-tube. An LPN combined multiple medications into a single cup without a physician's order, contrary to the facility's policy requiring separate administration with water flushes between each medication. The LPN was unaware of the policy, and the DON expected adherence to it.
The facility failed to ensure that residents with pressure injuries received necessary treatment and services, leading to the development and deterioration of pressure injuries. The facility did not perform necessary skin checks, obtain written orders for PRAFO boots, or update care plans in a timely manner, resulting in immediate jeopardy and actual harm to residents.
The facility failed to ensure adequate assistance devices for two residents, leading to a fracture for one resident during an improper transfer and the absence of a required fall mat for another high-risk resident. These deficiencies indicate a lack of adherence to Care Plans and fall prevention protocols.
A resident with an indwelling catheter experienced multiple hospitalizations due to sepsis from catheter-associated UTIs. Despite being cognitively intact and having a history of urinary retention, there was no documentation of a conversation about the risks and benefits of maintaining the catheter. The facility failed to document any formal assessment or attempt to remove the catheter, leading to repeated infections and hospitalizations.
The facility failed to properly date and label food items in the cooler and freezer, as observed during a kitchen inspection. Additionally, a large exhaust/vent above the dishwasher was found in poor condition, with duct tape used as a temporary fix. The vent had been obsolete since a new dishwasher was installed eight months prior. Staff interviews revealed a lack of awareness and action regarding these issues.
The facility failed to maintain a sanitary garbage storage area, with open lids on full bins and debris scattered around, as observed by surveyors. Staff interviews revealed that due to being short-staffed over the weekend, the responsibilities of ensuring closed lids and cleanliness were neglected, leading to the deficiency.
The facility's infection prevention and control program was deficient due to inadequate tracking and analysis of infection data. The Infection Preventionist was unfamiliar with the computer-based program, leading to discrepancies in infection records. Outbreaks of COVID-19 and RSV were not properly documented or managed, and the facility failed to implement effective surveillance and data analysis as outlined in their manual.
A resident sustained a fractured right tibia and fibula after a CNA did not follow the Care Plan for transfers, opting for a pivot transfer instead of using a sit-to-stand lift. The incident was not reported to the State Agency as required, as the Nursing Home Administrator and Regional Consultant incorrectly determined it was not a reportable event.
The facility failed to revise care plans for two residents and did not hold quarterly care conferences to ensure resident input. One resident's care plan was not updated to include showers twice a week, and another resident did not have care conferences on a quarterly basis, leading to deficiencies in their care.
A resident with severe cognitive impairment was not treated with dignity during meals, as staff stood while feeding and used the term 'feeder'. The CNA did not communicate with the resident about the meal and was observed watching TV. The facility's policy emphasizes promoting dignity and avoiding such labels.
A facility did not resubmit a PASARR Level I screen for a resident with Paranoid Schizophrenia and Bipolar Disorder after a 30-day exemption expired. The resident remained in the facility beyond the exemption period without a subsequent Level II screen. This was confirmed during a record review and an interview with the DON.
A resident on Eliquis, an anticoagulant, was not monitored for adverse effects such as bleeding or bruising, despite being at high risk for falls. The facility lacked a care plan for this medication, and the RN supervisor confirmed that monitoring was not typically done for Eliquis. The deficiency was noted by a surveyor, who found no interventions in the resident's care plan to address potential adverse reactions.
A resident prescribed Seroquel for anxiety did not receive the required AIMS assessment to monitor for side effects, as per facility policy. The resident, admitted with Anxiety, Depression, and Traumatic Brain Injury, was not assessed at the time of admission or when the medication was prescribed. The DON confirmed the oversight.
Failure to Notify Family of New Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident’s family of a significant change in condition when a new stage 3 pressure ulcer was identified. The resident was admitted with diagnoses including cancer with metastasis to the bone and a history of stroke, and an admission MDS showed a BIMS score of 13/15, indicating the resident was cognitively intact. On 10/28/25, a wound care note documented a newly identified stage 3 pressure ulcer on the left heel measuring 5.0 x 5.0 x 0.2 cm with 100% sanguineous drainage, and an order was entered for daily and PRN wound care with normal saline, Medi honey, ABD pad, and kerlix. There was no documentation in the EMR that any family member was informed of this newly identified wound. During an interview, the resident’s family member stated he was not notified of any wound. In a separate interview, the RN reported that the resident was considered “his own person” and had not specified who or whether he wanted family notified of the wound, noting that the resident had three emergency contacts and no designated resident representative. The RN also acknowledged there was no documentation in the EMR that the resident had been asked about family notification or that he declined such notification. The facility’s “Notification of Change in Condition” policy stated that for competent individuals, the facility must still contact the resident’s physician and notify the resident’s representative, if known, and that when a resident is mentally competent, a designated family member should be notified of significant changes in health status because the resident may not be able to notify them personally.
Failure to Implement Fall Prevention Intervention Results in Resident Fall
Penalty
Summary
A resident with severe vascular dementia, type 2 diabetes, and generalized osteoarthritis, who was assessed as being at high risk for falls, did not receive adequate supervision and assistance to prevent accidents. The resident's care plan included the use of Dycem, a non-slip material, in the wheelchair to prevent sliding and falls. On the date of the incident, the resident slid out of the wheelchair and fell to the floor; it was confirmed that the Dycem was not in place at the time of the fall. The facility's policy requires that individualized care plans and interventions, such as the use of Dycem, be communicated to all appropriate staff and implemented to prevent avoidable accidents. The resident's CNA Kardex also documented the need for Dycem in the wheelchair. Interviews and record reviews revealed that the CNA responsible for the resident did not ensure the Dycem was in place at the beginning of the shift, as required. The CNA acknowledged that the intervention was supposed to be checked but was not, and both the CNA and the unit manager confirmed that the absence of Dycem led to the fall. The facility's investigation determined that the root cause of the fall was the missing Dycem in the wheelchair, which was an established intervention for this resident. The resident was found on the floor without injury, and it was noted that the correct wheelchair cushion was present, but the Dycem was not. The deficiency was identified through interviews, record reviews, and the facility's own investigation, which confirmed that the required fall prevention intervention was not implemented at the time of the incident.
Failure to Maintain Sanitary Food Handling and Hair Restraint Practices in Kitchen
Penalty
Summary
Surveyors observed that food was not stored, prepared, and served under sanitary conditions in the facility's main kitchen. Specifically, a cook was seen pureeing food and preparing meal trays without a proper facial hair restraint, leaving his mustache exposed throughout food preparation and service. Additionally, the same cook failed to clean the thermometer probe between checking different food items. A dietary aide was also observed handling exposed, ready-to-eat foods with hair not fully contained under a hair restraint. These practices were witnessed during meal preparation and service, with both staff members directly handling food intended for residents. The facility's policy requires all dietary staff to wear appropriate hair restraints, including beard nets for facial hair, and to follow safe food handling procedures. The dietary manager confirmed these requirements during an interview and acknowledged observing the improper use of hair restraints but did not intervene at the time. The deficient practices had the potential to affect all 90 residents who received meals from the main kitchen, as all food for the facility is prepared and served there.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS for the second quarter of 2025 was accurate and based on payroll and other verifiable and auditable data, as required. During a review of the Payroll-Based Journal (PBJ) staffing data, the facility was flagged for excessively low weekend staffing, which had the potential to affect all 90 residents. The facility's own assessment documented staffing needs and also triggered for low weekend staffing during the same period. However, upon review of nursing schedules and posted staff hours, no documented trends or gaps in weekend staff coverage were found. Interviews with the scheduler and the Director of Recruitment (DOR) revealed that the facility does not use agency staff and typically overstaffs on weekends to cover call-ins, with no reported staffing concerns. The DOR, responsible for submitting PBJ reports, stated that the system alerted them to being in the bottom 20th percentile for staffing, but did not investigate the cause of this alert, which affected all company facilities. The Nursing Home Administrator (NHA) was not aware of any staffing alerts or low weekend staffing. No further information was provided to explain why the submitted staffing data was inaccurate or did not align with verifiable records.
Failure to Complete MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete admission and annual comprehensive Minimum Data Set (MDS) assessments within the required timeframes for six out of eight residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, admission MDS assessments must be completed by the end of day 14 after admission, and annual assessments must be completed at least every 366 days. The report details that several residents had their admission or annual MDS assessments either completed late or still in progress well past the required deadlines. For example, one resident's admission MDS was completed 24 days late, another's annual MDS was still in progress at the time of survey, and others had similar delays or incomplete assessments. The deficiency was attributed to staffing issues within the MDS coordinator team. The full-time LPN responsible for MDS assessments had been on medical leave for three months, and although coordinators from sister facilities provided some assistance, the extent of their coverage was unclear. The LPN and the Nursing Home Administrator both acknowledged awareness of the late assessments and attributed the delays to difficulties in staffing the MDS coordinator position during the period in question. No additional information regarding the residents' medical histories or conditions at the time of the deficiency was provided.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. This deficiency was identified based on a review of assessment records and transmission logs, which showed that required assessment data were not submitted to the State within the mandated timeframe. The delay in data transmission was directly related to the facility’s inaction in meeting the 7-day submission requirement following the completion of resident assessments.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
Surveyors observed that the facility did not ensure food was prepared to conserve nutritive value and flavor for residents on a pureed diet. Specifically, a cook was seen preparing pureed cornbread without following a standardized recipe, as required by facility policy. The cook placed unmeasured amounts of cornbread, milk, and thickening powder into a blender, blended the mixture, and produced a consistency thinner than pudding, which did not meet the expected standard for pureed foods. When questioned, the cook was unable to describe the correct consistency or confirm adherence to a recipe. The Dietary Manager confirmed that recipes exist for all pureed foods and acknowledged that the cook should have followed the recipe to achieve the correct texture. The facility's policy mandates the use of standardized recipes for all menu items, and the failure to follow these procedures was observed to affect all residents receiving pureed diets at the facility. No explanation was provided for the cook's deviation from the required process.
Failure to Document and Resolve Resident Grievance Regarding Meal Portions
Penalty
Summary
A deficiency occurred when the facility failed to address and resolve a resident's grievance regarding meal portion sizes. The resident, who was cognitively intact and had multiple medical diagnoses including a left femur fracture, COPD, diabetes, and heart failure, reported concerns about not consistently receiving double portions with meals as requested. The resident communicated these concerns to their assigned caring partner, a CNA Scheduler, but there was no documentation of the grievance in the facility's grievance log, and the resident's care plan and meal tickets did not reflect the request for double portions. The facility's policy requires that all grievances be documented and forwarded to the grievance official, but this process was not followed in this case. Interviews with staff revealed that the CNA Scheduler, who was new to both the facility and long-term care, did not complete a grievance form or report the concern to social services, believing the issue was addressed verbally with the Dietary Manager. The Dietary Manager confirmed the concern was handled verbally and acknowledged that the meal tickets did not reflect the resident's preferences, which was an oversight. The Social Services Director was unaware of the concern and reiterated that all grievances should be documented. The lack of documentation and formal follow-up resulted in the resident's grievance not being properly addressed according to facility policy.
Late Completion of Quarterly MDS Assessment Due to Staffing Shortages
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment was completed within the required timeframe as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that quarterly MDS assessments must be completed at least every 92 days following the previous assessment, and the completion date must be no later than 14 days after the Assessment Reference Date (ARD). In this case, the resident’s quarterly MDS assessment was completed 20 days after the required deadline. The delay was attributed to staffing challenges within the MDS coordinator team. The full-time LPN responsible for MDS assessments had been on medical leave for three months, and although coordinators from sister facilities assisted during this period, the extent of their coverage was unclear. Upon returning, the LPN and the Nursing Home Administrator acknowledged the late completion of the assessment and cited difficulties in maintaining adequate MDS staffing during the absence.
Failure to Timely Revise Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to revise care plans and conduct timely care conferences for two residents, as required by policy and regulatory standards. For one resident with diagnoses including pneumonia, acute respiratory failure, hypertension, dysphasia, depression, and anxiety, the comprehensive care plan was not completed within the required timeframe after admission. The initial care plan did not include focus areas for hearing deficit or depression, despite documented evidence of moderate depression and a known hearing impairment. The care plan was not updated to address these issues until more than a month after admission, and only after the surveyor brought the omissions to the facility's attention. Interviews with staff revealed a lack of clarity regarding responsibility for updating care plans and acknowledged that the required focus areas were not included initially. Another resident with multiple chronic conditions, including COPD, asthma, morbid obesity, diabetes, congestive heart failure, bipolar disorder, anxiety, depression, panic disorder, and PTSD, did not have a care conference scheduled following a quarterly MDS assessment. The resident was unaware of care conferences and expressed interest in participating. Documentation showed that the last care conference occurred several months prior, and no subsequent conference was scheduled in accordance with the facility's policy and the MDS assessment schedule. Staff interviews confirmed that the care conference had not been held as required and that scheduling was delayed. The facility's policy mandates that comprehensive care plans be developed within seven days of completing the comprehensive MDS assessment and that care conferences be held quarterly or in accordance with the MDS schedule. In both cases, the facility did not adhere to these requirements, resulting in incomplete or delayed care planning and lack of resident involvement in care conferences.
Failure to Ensure Resident Privacy Due to Faulty Door
Penalty
Summary
The facility failed to ensure the proper functioning of a resident's door, compromising the resident's privacy and safety. The resident, who was cognitively intact and admitted with bilateral primary osteoarthritis of the knee, reported that the door to their room did not stay closed, which had been an issue since September. To keep the door shut, a CNA suggested using a towel and pillowcase, which the resident implemented. The resident expressed concern about privacy, particularly when using the commode, as the door's inability to close properly allowed others to see inside. During an observation, it was confirmed that the door latch did not engage with the strike plate, preventing the door from staying closed. The facility's Administrator acknowledged the issue, attributing it to weather-related expansion and contraction. However, the Unit Manager/RN was unaware of the problem, indicating a lack of communication or follow-up on maintenance work orders. This oversight resulted in a failure to maintain a safe and private environment for the resident.
Failure to Document and Administer Insulin and FSBS
Penalty
Summary
The facility failed to ensure proper documentation and administration of a fingerstick blood sugar test (FSBS) and insulin for a resident with type one diabetes. The resident, who was cognitively intact, was admitted with diagnoses including type one diabetes with ketoacidosis and coma. The facility's policy on medication errors emphasizes the importance of verifying the right medication, dose, route, time, resident, and documentation to prevent errors. However, the Medication Administration Record (MAR) for December 2024 showed that insulin Lispro was not documented as administered on two occasions, and there was no record of an FSBS being obtained or insulin being administered as per the sliding scale on the same dates. The Director of Nursing (DON) confirmed during an interview that the registered nurse responsible for the resident's care admitted to forgetting to document due to being busy, but did not confirm whether the insulin or FSBS had been administered. The lack of documentation and potential failure to administer the prescribed insulin and FSBS placed the resident at risk for serious medical consequences, as the resident's condition requires careful monitoring and management of blood sugar levels.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure the Medication Administration Record (MAR) and Treatment Administration Record (TAR) were complete and accurate for two residents. For Resident 10, the MAR did not reflect the administration of several medications as per physician orders. These medications included an antibiotic, a dementia medication, a GERD medication, an iron supplement, a cough syrup, and a breathing medication. The Director of Nursing (DON) confirmed that the medications were administered but not documented by the responsible nurses, RN4 and LPN3. Resident 7's TAR was incomplete, failing to document the administration of wound care treatments for pressure injuries. The treatments were not recorded on multiple occasions, despite the resident confirming that wound care was generally provided. The DON stated that if a resident was out of the facility, the information should be passed to the next shift, and the treatment should be documented as administered or noted that the resident was unavailable. Interviews with the DON revealed that the nurses responsible for administering medications and treatments did not document them due to being busy or forgetting. The expectation was for documentation to occur immediately after administration or to note the resident's absence. The lack of documentation for both residents indicates a failure to adhere to the facility's policy on medication and treatment administration documentation.
Failure to Follow Prescribed Menu for Resident Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for all diets listed on the menu spreadsheet, affecting all 81 residents who receive meals from the facility. During lunch observations, it was noted that the portions served did not match the menu specifications. Specifically, residents on regular and mechanical soft diets were served 5.3 ounces of Chicken Cacciatore mixed with pasta instead of the prescribed 6 ounces of Chicken Cacciatore and 4 ounces of Penne pasta. Additionally, they received 3 ounces of carrots instead of the 4 ounces specified. Residents on puree diets were served 4 ounces of puree chicken instead of the 8 ounces of puree chicken cacciatore and 4 ounces of puree penne pasta as outlined in the menu. Interviews with the Dietary Manager confirmed that the cook was not following the menu for any of the diets. The Dietary Manager acknowledged the discrepancies in portion sizes and confirmed that the menu was not being adhered to. Furthermore, during lunch observations, three unidentified residents expressed that they often did not receive enough food during meals. The Administrator also stated that she expected the menu to be followed, indicating a lack of oversight in ensuring compliance with dietary requirements.
Inconsistent Water Temperature Monitoring in Facility
Penalty
Summary
The facility failed to maintain water temperatures within the safe and comfortable range of 110 to 120 degrees Fahrenheit, as outlined in their policy. Observations and interviews revealed that water temperatures in various units were either too cold or excessively hot, posing potential risks for burn-related injuries or discomfort during showers. Specifically, water temperatures in the South, North, and West units fluctuated significantly, with some readings as low as 81 degrees Fahrenheit and others as high as 139 degrees Fahrenheit. These inconsistencies affected 36 of the 81 residents in the facility, with some residents reporting discomfort during showers and others experiencing dangerously hot water in their sinks. The Maintenance Employee (ME) admitted to checking water temperatures at the hot water tanks weekly but only randomly checking temperatures in resident rooms without documenting them. The facility's Administrator and Regional Nurse Consultants were unaware of a water temperature policy, and the monitoring logs provided did not include temperatures from resident bathrooms or shower rooms. The Administrator confirmed that water temperatures were not regularly monitored in these areas, despite the facility having four shower rooms and 81 resident bathrooms. This lack of consistent monitoring and documentation contributed to the deficiency in maintaining safe water temperatures.
Failure to Maintain Functioning Call System in North Station
Penalty
Summary
The facility failed to maintain a functioning call system with auditory alarms in the North station, affecting 22 residents. The call light panel behind the nursing station did not work, and staff were unaware of how long it had been non-functional. Observations confirmed that while the call lights over individual room doors were operational, the panel at the nurse's station neither lit up nor made noise, which was corroborated by maintenance staff. Interviews with staff, including a Certified Medication Tech, a Registered Nurse, and a Certified Nurse Aid, revealed that the issue had persisted for about a month, and although it was reported verbally, no formal work order had been submitted until the surveyor's visit. The maintenance employee confirmed the malfunction and indicated that the system was too old for repair by several companies, though a potential solution was being explored. The facility's policy required call light system defects to be reported to the Maintenance Department for servicing, but this protocol was not followed, as evidenced by the lack of a work order. The Administrator acknowledged the issue and confirmed that while the visual alert was functional, the auditory alarm was not, and she had only verbally informed the maintenance staff without submitting a work order initially.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure there was a physician's order for oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD). The resident was readmitted to the facility and was not initially assessed as using oxygen during the assessment period. The resident's care plan included interventions for COPD but did not mention oxygen therapy. A review of the resident's physician orders revealed no order for oxygen therapy, despite the resident being tried on oxygen due to low oxygen saturations. The deficiency was highlighted when the resident was sent to the hospital emergently for low oxygen saturation. The resident's oxygen saturation improved after increasing the oxygen from 2L to 5L. A pulmonologist's note indicated that the resident was using 3L of oxygen and felt better with it. However, the Director of Nursing acknowledged that the oxygen order was not processed, leading to the deficiency in providing appropriate respiratory care.
Failure to Follow G-Tube Medication Administration Policy
Penalty
Summary
The facility failed to adhere to its medication administration policy for a resident who was ordered to receive medications via a gastrostomy tube (g-tube). The resident, identified as R8, had specific medication orders that required each medication to be administered separately with a flush of tepid water between each to prevent the g-tube from becoming clogged. However, during an observation, an LPN was seen preparing to administer multiple medications as a cocktail, combining them into a single cup without a physician's order to do so. This action was contrary to the facility's policy, which mandates the separate administration of medications. The incident involved the administration of Docusate Sodium, Keppra, Guaifenesin, and Famotidine, with the latter being crushed and mixed with the liquid medications. The LPN was unaware of the facility's policy regarding the administration of medications via a g-tube, which was confirmed during an interview. The Director of Nursing later stated that it was expected for the LPN to follow the facility's policy, highlighting a lapse in adherence to established procedures for medication administration.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing. Specifically, the facility did not perform checks each shift to monitor the skin under PRAFO boots for a resident, leading to the development of a stage 4 pressure injury. The facility also failed to obtain written orders on the length of time the PRAFO boots should be worn and did not update the resident's plan of care for over a month regarding the pressure wound. A comprehensive assessment of the wound was not documented until the wound doctor saw the resident on 2/5/2024, despite the wound being discovered on 1/30/2024. This created a finding of Immediate Jeopardy at a scope and severity of a J (immediate jeopardy/isolated) that began on 1/30/2024. The immediate jeopardy was removed on 4/24/2024 when the facility implemented their action plan, but the deficient practice continued at a scope and severity of a G (actual harm/isolated) for other residents reviewed for pressure injuries. Another resident was admitted to the facility from the hospital with an unstageable pressure injury on the coccyx, which deteriorated to a stage 4 pressure injury with multiple courses of antibiotics after admission. The resident developed multiple infections related to possible soiled dressing from stool that were not addressed in the treatment record to change dressings as needed. The resident's air mattress was observed set to a higher weight load than what the resident weighed, and the facility did not establish a clear, individualized plan of care regarding repositioning for the resident. Additional observations included residents with air mattresses set to incorrect weight loads, a resident developing a facility-acquired stage 3 pressure injury due to the lack of an individualized repositioning schedule, and another resident with a sacral pressure injury and a chronic left heel pressure injury that was not comprehensively assessed by a Registered Nurse until days after the wound reopened. The facility's policy and procedure for pressure ulcers/skin integrity/wound management were not followed, leading to these deficiencies.
Removal Plan
- R78 no longer uses his PRAFO boots.
- Orders for splint/brace and skin integrity checks will be reviewed by nursing and initiated.
- Care plans have been reviewed and reflect the use of the splint/brace.
- Any new or worsening skin integrity issues will require a documented comprehensive RN assessment. This will include physician notification and care plan review.
- Nursing staff to be educated on identifying a splint/brace along with the risk for skin breakdown related to the device.
- Nursing staff to be educated on following the wearing schedule for splint/braces and completing skin integrity checks according to the plan of care.
- Nursing staff will receive education on the need for an RN assessment when any new or worsening wound is found.
- Facility reviewed the policy for prevention of pressure injuries.
- Medical Director is aware and involved in plan.
- DON/designee will audit all brace/splint monitoring orders and wearing schedules to ensure completion.
- DON/Nurse Managers will audit skin checks for braces/splints to ensure compliance.
- Results of audits will be reviewed through the QAPI process and make changes as necessary.
Failure to Follow Care Plans and Use Assistive Devices
Penalty
Summary
The facility did not ensure that residents received adequate assistance devices to prevent accidents for two residents. One resident, R65, was transferred using a pivot transfer instead of the sit-to-stand lift as indicated in their Care Plan. During the transfer, R65's leg became trapped, resulting in a fracture of the right tibia and fibula. The investigation revealed that the CNA did not follow the Care Plan and performed a pivot transfer based on the resident's request, leading to the injury. The resident was subsequently treated at the hospital and readmitted with an external fixation device and non-weight bearing instructions for the right leg. Another resident, R67, was observed multiple times without a fall mat in place as required by their Care Plan. Despite being at high risk for falls, the fall mat was not found on the right side of the bed during several observations. The LPN confirmed that the fall mat should have been in place, but it was not. This lack of adherence to the Care Plan posed a significant risk to the resident's safety. These deficiencies highlight the facility's failure to implement and maintain individualized fall prevention strategies as outlined in their Fall Prevention Program. The lack of proper supervision and use of assistive devices directly contributed to the accidents involving R65 and R67, indicating a need for improved adherence to Care Plans and staff training on fall prevention protocols.
Failure to Assess Indwelling Catheter Removal
Penalty
Summary
The facility did not ensure that a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible. The resident, who was admitted with a urinary catheter, had multiple hospitalizations due to sepsis caused by catheter-associated urinary tract infections (UTIs). Despite being cognitively intact and having a history of urinary retention, there was no documentation of a conversation with the resident about the risks and benefits of maintaining the catheter. Additionally, there was no evidence that the catheter was recommended for wound healing by a wound physician, even though it was cited as a reason for its continued use. The resident had a significant medical history, including malnutrition, anorexia, diabetes, polyneuropathy, adult failure to thrive, and depression. The resident's care plan included monitoring for catheter complications and pain, but there was no documentation of a voiding trial to assess the necessity of the catheter. The resident expressed a preference for keeping the catheter due to limited mobility and convenience, but this preference was not adequately documented or assessed for medical necessity. Interviews with nursing staff revealed a lack of clarity about whether a voiding trial had been attempted and whether the resident had been informed of the risks associated with long-term catheter use. The resident experienced multiple episodes of catheter clogging and leakage, which were not promptly addressed. The facility failed to document any formal assessment or conversation regarding the removal of the catheter, leading to repeated infections and hospitalizations for the resident.
Deficiencies in Food Storage and Kitchen Ventilation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen inspection. In the reach-in cooler, a large open bag of shredded cheese and two large pieces of uncooked pork were found without proper labeling or dating. The Dietary Manager was unable to provide an explanation for the oversight, indicating that the cook should have dated and labeled the foods. Additionally, in the kitchen freezer, a large box of uncovered lettuce with brown edges and an open bag of Hormel Breakfast Sausage Crumble were found without dates, further highlighting the facility's failure to comply with its own food storage policy. Another significant issue was identified with the kitchen's exhaust/vent system. A large silver metal exhaust/vent located above the dishwasher was observed to be in poor condition, with red duct tape wrapped around it and cold air blowing directly in front of the dishwasher. The vent had been in this state since the installation of a new dishwasher eight months prior, and the maintenance staff admitted to using duct tape as a temporary fix. The vent was originally part of the old dishwasher's exhaust system and was deemed obsolete with the new dishwasher installation. Interviews with the facility's staff, including the Dietary Manager, Maintenance Assistant, and Maintenance Director, revealed a lack of awareness and action regarding the exhaust/vent issue. The Registered Dietician confirmed that the responsibility for dating and labeling foods lay with the dietary manager or cooks. The facility's Administrator acknowledged the presence of the outdated exhaust/vent system since the new dishwasher's installation but had not addressed the issue until the surveyor's observation.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to maintain the outside garbage storage area in a sanitary condition, as observed by surveyors. On the first observation, three large metal garbage bins were found to be full with their lids open, and the surrounding area was littered with various debris, including garbage bags, paper cups, medication cups, Styrofoam cups, used gloves, and a soiled adult brief. A metal rodent trap was also noted to be empty. The Dietary Manager acknowledged that the area should be clean and the lids should be closed, indicating a lapse in maintaining the area as per the facility's pest control policy. Further interviews revealed that the Maintenance Director and Plant Operations Manager were aware that the lids should always be closed and the area kept clean. However, due to being short-staffed over the weekend, these tasks were not completed, leading to the observed unsanitary conditions. The Plant Operations Manager admitted that the CNAs and other staff were responsible for ensuring the cleanliness and closure of the garbage bins, but due to staffing issues, these responsibilities were neglected, resulting in the deficiency.
Inadequate Infection Control Program and Data Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate tracking, trending, and analysis of infection data. The Infection Control Program did not accurately identify infections within the facility, and there was no system of surveillance, including mapping to identify monthly infections on units. The Infection Preventionist (IP) was not familiar with the computer-based Infection Prevention program, which hindered the facility's ability to analyze and maintain infection data effectively. The facility experienced an outbreak of COVID-19 in December 2023 and two outbreaks of RSV in March and April 2024. However, there were no summaries, timelines, contact tracing, or documentation explaining the course of these outbreaks or the steps taken to mitigate them. The surveyor noted discrepancies between handwritten line lists and the computer-generated infection control log, indicating a lack of accurate record-keeping and data analysis. Interviews with the IP and facility administrators revealed that the IP was new to the position and lacked training in using the computer program for infection data analysis. The facility's Infection Prevention and Control Manual outlined the necessary elements of a surveillance system, but these were not effectively implemented. The surveyor's review of the facility's documentation and interviews with staff highlighted significant gaps in the infection prevention and control program, contributing to the deficiency.
Failure to Report Incident of Neglect Resulting in Serious Injury
Penalty
Summary
The facility failed to report an incident of neglect that resulted in serious bodily injury to the State Agency. A resident, who was dependent on staff for transfers and required the use of a sit-to-stand lift as per their Care Plan, was transferred by a CNA using a pivot transfer instead. This deviation from the Care Plan led to the resident sustaining a fractured right tibia and fibula. The incident was not reported to the State Agency as required by the facility's policy and procedure on abuse and neglect reporting. The resident, who had diagnoses including malnutrition, diabetes, and moderate cognitive impairment, complained of severe pain in the right leg following the improper transfer. The resident was subsequently transported to the hospital for evaluation and treatment, where the fractures were confirmed. The CNA involved in the incident admitted to not following the Care Plan, citing the resident's preference and previous therapy sessions as reasons for attempting the pivot transfer. The Nursing Home Administrator and Regional Consultant reviewed the incident and determined it was not intentional and did not fit the definition of abuse, thus deciding it was not a reportable event. However, this decision was based on a flow chart not intended for nursing home use, leading to the failure to report the incident to the State Agency within the required timeframe.
Failure to Revise Care Plans and Hold Quarterly Care Conferences
Penalty
Summary
The facility did not revise resident care plans for two residents and failed to ensure care conferences were held quarterly to get resident input in their care. One resident's care plan was not updated to include showers twice a week as discussed with the resident's guardian, resulting in the resident not receiving the agreed-upon showers. The resident had severe cognitive impairment and required substantial assistance for personal hygiene, including the use of a Hoyer lift for transfers. Despite a grievance filed by the resident's guardian, the care plan and care Kardex were not revised to reflect the new shower schedule, and the resident's medication administration record showed inconsistent documentation of shower days. Another resident did not have care conferences on a quarterly basis to ensure participation in the development of their care plan. The resident had moderate cognitive impairment and required substantial assistance for daily activities. The facility's policy stated that care plan conferences should be held at least quarterly, but documentation showed significant gaps between care conferences. The resident's first care conference was held several months after admission, and subsequent conferences were not held quarterly as required. The lack of documentation and follow-up on scheduled care conferences indicated a failure to adhere to the facility's policy. Interviews with staff, including social services and the unit manager, revealed a lack of communication and follow-through regarding grievances and care plan updates. The unit manager did not recall the specific concerns about the resident's shower schedule, and social services did not have documentation of care conferences for the second resident. The facility's failure to revise care plans and hold regular care conferences led to deficiencies in the care provided to the residents.
Failure to Ensure Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure dignity for a resident during meal times, as observed in two separate instances. The resident, who has severe cognitive impairment due to Alzheimer's disease and other forms of dementia, requires substantial assistance with eating. During a breakfast observation, a Certified Nursing Assistant (CNA) was seen standing while feeding the resident, without engaging in any communication about the meal. The CNA was also observed watching television instead of interacting with the resident, who was non-communicative and reliant on the CNA for feeding. In a subsequent meal observation, the same CNA was again standing while feeding the resident and did not communicate what the resident was eating. Another staff member, the HR Coordinator, temporarily took over feeding duties and also stood while interacting minimally with the resident. The CNA and HR Coordinator conversed with each other over the resident, who remained non-communicative and dependent on the staff for feeding. Interviews with the CNA revealed a preference for standing while feeding residents, and the use of the term 'feeder' to describe residents requiring assistance with meals. The facility's Administrator expressed that staff should engage with residents during meals and should not refer to them as 'feeders'. The facility's policy emphasizes promoting resident dignity and avoiding labels such as 'feeders', as well as encouraging staff to sit while assisting residents with meals.
Failure to Resubmit PASARR Level I for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure compliance with the Preadmission Screening and Resident Review (PASARR) process for a resident diagnosed with Paranoid Schizophrenia and Bipolar Disorder. The resident was admitted with a PASARR Level I screen that included a 30-day exemption due to a hospital discharge and an expected short-term stay. However, when the resident remained in the facility beyond the 30-day exemption period, the facility did not resubmit a PASARR Level I screen to the State mental health authority, nor was a subsequent Level II screen completed. This oversight was confirmed during a record review and an interview with the Director of Nurses, who acknowledged that the necessary PASARR Level I should have been completed after the 30-day period expired.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the anticoagulant Eliquis. The resident, who has multiple diagnoses including end-stage renal disease, diabetes, and vascular dementia, was admitted with an order for Eliquis to be taken twice daily. However, the facility did not implement a care plan or orders to monitor for adverse side effects associated with the anticoagulant, such as bleeding or bruising. This oversight was noted despite the resident's high risk for falls, which increases the risk of bleeding when on an anticoagulant. The surveyor's review of the resident's medication administration record and comprehensive care plan revealed a lack of monitoring for signs and symptoms of adverse effects from Eliquis. During an interview, the registered nurse supervisor indicated that typically only Coumadin or Warfarin are monitored and care planned, and there was no specific plan for monitoring Eliquis. The surveyor found no interventions related to monitoring for adverse reactions in the resident's cardiovascular care plan. These findings were shared with the nursing home administrator, who did not provide further information at the time.
Failure to Conduct AIMS Assessment for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving anti-psychotic medication was assessed for potential side effects. Specifically, a resident identified as R82, who was prescribed Seroquel for anxiety, did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed as required by the facility's policy. The policy mandates that such an examination be performed at the time of admission or when the medication is initially prescribed. R82 was admitted with diagnoses including Anxiety, Depression, and Traumatic Brain Injury, and was prescribed Seroquel on 3/22/24. However, upon review of R82's medical records on 4/23/24, no AIMS assessment was found. The Director of Nurses confirmed that the assessment was not completed, acknowledging the oversight.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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