Avina Of Milwaukee
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 9255 N 76th St, Milwaukee, Wisconsin 53223
- CMS Provider Number
- 525523
- Inspections on file
- 31
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 51
Citation history
Health deficiencies cited at Avina Of Milwaukee during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including neuropathy, DM2, COPD, and heart failure, who was cognitively intact and frequently incontinent, reported that a CNA refused or failed to provide requested toileting and incontinence care for an entire day shift, leaving the resident in urine‑soaked linens until the next shift. The resident described feeling like garbage, useless, and severely abused, and was found by a second‑shift CNA in a soaked brief and bed, requiring a full bed bath, linen change, and cleaning of the mattress. Multiple staff, including a CNA, the ADON, and a social worker, were informed of the allegation, but there was no contemporaneous documentation in progress notes, no entry on the grievance log initially provided, no self‑report to the state, and the NHA was not notified. A handwritten grievance later produced described the same events but contained no documented investigation, follow‑up, or resolution, demonstrating a failure to provide timely incontinence care and to recognize, report, and investigate an allegation of neglect as required by facility policy.
A cognitively intact resident with multiple chronic conditions, including diabetes, CKD, and dementia, had an order for oral cholecalciferol but no assessment, MD order, or care plan authorizing self-administration. A medication technician crushed the vitamin D tablet, mixed it with applesauce, placed it with water on the bedside table, informed the resident it was there, and left without observing ingestion. Later observations found the medication still untouched. An LPN and the DON reported that facility policy requires staff to remain and observe medication consumption and prohibits leaving medications at the bedside without a physician order and documented self-administration assessment and care plan.
Two residents, both cognitively intact and with multiple chronic conditions, filed grievances regarding lack of incontinence care and food service issues, including a fly on a meal tray and missing salads. The facility’s grievance records showed minimal follow-up, with only brief notations by the DON and Dietary Manager, no clear investigation steps, conflicting or inaccurate dates, and no documented confirmation or non-confirmation of the allegations. Required elements of the facility’s grievance policy—such as thorough investigation, interdisciplinary review, and communication of the outcome to the residents or their representatives—were not documented as completed.
Two residents reported allegations of abuse/neglect that were not promptly reported to the NHA or State Agency as required. In one case, a cognitively intact, frequently incontinent resident with multiple chronic conditions stated that a CNA refused to provide incontinence care for an entire day shift despite repeated requests, leaving the resident in urine-soaked linens until a 2nd-shift CNA provided care and reported the incident to the ADON and a social worker. Although a grievance form was later found documenting that the resident’s toileting and incontinence needs were not met and that 2nd-shift staff had to change the bed, clothing, and brief, the grievance was not on the grievance log initially provided, contained no investigation or resolution, and the NHA was unaware of the allegation. Staff interviews showed inconsistent understanding of reporting expectations, and the facility’s abuse/neglect policy requiring immediate reporting and investigation was not followed, resulting in a deficiency for failure to timely report and investigate alleged abuse/neglect and to notify proper authorities.
Two residents reported serious concerns of neglect and abuse that were not promptly reported to the NHA or thoroughly investigated as required by facility policy. One resident, cognitively intact and dependent on staff for toileting and hygiene, alleged that a CNA ignored repeated requests for incontinence care for an entire shift, leaving the resident wet and distressed until another CNA provided full care; although a grievance form was later found, it was not logged, contained no investigation or resolution, and the NHA was never notified. Another resident with dementia and other comorbidities reported that a CNA was rough with morning cares and threw a breakfast tray, and these allegations were relayed by CNAs to an LPN and a social worker, yet there was no documented investigation, no grievance entry on the log, and the NHA did not recall being informed. In both cases, staff failed to follow the abuse/neglect policy requiring immediate reporting, comprehensive investigation, and complete documentation of alleged violations.
Two residents with multiple comorbidities, including severe protein-calorie malnutrition and neurologic and cardiovascular conditions, were served meals that were not safe, attractive, or palatable. One resident, cognitively intact and independent with eating, photographed peaches on a meal tray that appeared to have white and green mold, and an LPN confirmed seeing mold and removed the peaches. The same resident also photographed a fly on mixed vegetables. Another cognitively intact resident filed a grievance reporting a lunch tray with a fly on it; the grievance documentation showed the DM spoke with the resident but did not document addressing the fly itself, and later stated they believed the resident had already been discharged. The DM acknowledged flies might be present due to a steam table located near an outside door, while the MD reported not being informed of any fly issue, and the NHA did not recall being told about mold or flies on residents’ food.
The facility failed to conduct and document required quarterly, interdisciplinary care plan conferences that allow resident and family participation in person-centered care planning. One cognitively intact resident reported that scheduled care conferences never occurred and record review confirmed no quarterly conferences over several months. Another resident with severe cognitive impairment and multiple chronic conditions had no documented care conferences, and the SW responsible for conferences acknowledged none had been completed. A third resident with Alzheimer’s disease and other comorbidities had no evidence of a care conference in the prior year, and the SW confirmed not having held any, with no supporting documentation available when leadership was informed.
A cognitively intact resident with multiple chronic conditions, including cervical radiculopathy, BPH, adult failure to thrive, pulmonary HTN, and depression, reported to an RN that two night-shift CNAs had "roughed him up" while providing ADL care, including allegedly holding his wrists and pulling him while changing his brief despite his insistence that he was not wet. The RN documented the complaint, notified the DON, and obtained CNA statements, but the allegation of potential abuse was not reported to the State survey agency or the NHA as required by the facility’s abuse, neglect, and exploitation policy, and the NHA later confirmed there were no incident reports submitted for this resident during the review period.
A cognitively intact resident with multiple medical conditions, including cervical radiculopathy, BPH, and incontinence, reported that two CNAs insisted on changing him despite his statement that he was not wet, allegedly held his wrists, pulled him causing shoulder pain, and "roughed him up" during nocturnal ADL care. The RN on duty documented the complaint, notified the DON, and obtained written statements from the two CNAs. However, the DON did not interview the resident, the CNAs, or the RN, did not conduct a formal investigation, and only retained the CNA statements. No other residents were interviewed to assess for similar concerns, resulting in a failure to follow the facility’s abuse/neglect investigation policy requiring immediate, thorough investigation and interviews of all involved persons.
A resident with multiple medical conditions, severe cognitive impairment, high fall risk, and specific hospital discharge instructions for diet, supervision, and mobility was admitted, but the facility failed to develop and implement a person-centered baseline care plan within 48 hours. Despite policy requiring individualized goals and interventions based on admission assessments and hospital information, the baseline care plan and CNA Kardex contained generic, incomplete entries that did not specify needed assistance with ADLs, mobility, incontinence care, skin integrity, or fall prevention, and omitted key instructions such as 1:1 supervision and pureed diet with no straws. The DON later acknowledged that the non-specific care plan and Kardex did not provide staff with clear guidance on how to safely care for the resident.
A resident with multiple comorbidities, including dementia and a history of falls, had two unwitnessed falls on the same day, after which staff initiated but did not complete neurological checks as required by facility policy. The policy called for a defined series of neuro assessments (Q15 minutes, then Q1 hour, then Q shift for 72 hours) after unwitnessed falls or head injuries, including evaluation of consciousness, speech, pupils, hand grasps, and vital signs. Documentation showed only partial completion of the ordered neuro‑check sequence after each fall, and the DON confirmed the expected schedule and documentation requirements but could not provide a reason why the full series of checks was not carried out.
Two residents at high risk for falls, both with cognitive impairment and mobility limitations, experienced multiple falls after admission while the facility relied on generic fall interventions such as keeping the call light within reach and following facility protocol. For one resident, therapy and hospital records documented significant balance, judgment, and safety‑awareness deficits, yet the baseline care plan and CNA Kardex lacked specific, person‑centered instructions for bed mobility, transfers, ambulation, and supervision. This resident had three falls within a short period, including two unwitnessed falls and a later witnessed fall at the nurses’ station resulting in a head laceration, but the facility failed to complete thorough fall investigations, obtain staff statements, clarify circumstances of the falls, or perform root cause analyses. The second resident, also care‑planned only with generic fall measures, sustained an unwitnessed fall while getting out of bed, and the fall investigation lacked details on when the resident was last seen or toileted, with the DON confirming no additional information was available.
Surveyors found that the facility did not conduct or document required safety inspections of any of the 77 resident beds, including those with assist or mobility bars. The NHA confirmed there was no policy for bed inspections, and the Maintenance Director reported that while informal checks are done at admission (such as removing safety bars, checking for a mattress, testing remotes, and looking for exposed wires), these checks are not documented. Review of the MIFU for Joerns beds showed a requirement for monthly visual inspections for broken welds, cracks, and loose hardware, which were not documented. Additionally, although FDA guidance on seven bed entrapment zones and dimensional limits was available, the Maintenance Director stated that FDA entrapment zone measurements were not performed or documented for any of the 36 residents using bed rails, mobility bars, or assist bars.
The facility failed to maintain and serve hot food at safe temperatures, as required by its food safety policy and FDA Food Code standards. A cognitively intact resident with severe protein-calorie malnutrition and multiple comorbidities reported that meals were cold and not always reheated by staff. During an observed evening meal, the DM measured the resident’s chicken and noodles at 93.7°F directly from the transport cart, despite policy requiring monitoring of holding temperatures and reheating cooked foods to 165°F or heating ready-to-eat foods to at least 135°F. Federal guidance cited in the report notes that food held in the 40–140°F “Danger Zone” can support bacterial growth and that hot foods should be kept at or above 140°F.
A resident with stroke-related deficits, parkinsonism, left-sided hemiplegia/hemiparesis, and moderately impaired cognition was assessed on the MDS as needing assistance with meal setup and cleanup. During a lunch observation, the resident sat alone with the meal plate still covered in plastic wrap, which he had only partially torn and not fully removed, until the Dining Services Manager removed it and stated that serving staff should have done so. A CNA acknowledged she should have removed the plastic wrap, while the DON and Nursing Home Administrator both stated that CNAs are required and expected to complete meal setup for residents when indicated, consistent with the facility’s ADL policy requiring assistance with meal setup based on assessed needs.
A resident with hypoglycemia, diabetes, and diabetic chronic kidney disease had an order for acarbose 25 mg to be given orally three times daily before meals, but medication records showed repeated late administrations and, on one occasion, two scheduled doses documented at the same time. The NHA reported there was no facility policy on medication administration, and the DON stated medications were expected to be given as ordered, acknowledging that the recorded times fell outside normal leeway and were not properly documented in relation to meal delivery, despite acarbose being intended for administration with the first bite of each meal.
A resident who was cognitively intact and dependent on staff for mobility reported being left for several hours without incontinence care after their ostomy bag broke, despite multiple calls for assistance. Although the concern was brought to the attention of the Director of Social Services and the Nursing Home Administrator, staff did not initiate a formal grievance or conduct an investigation as required by facility policy.
A resident with multiple mental health and medical diagnoses was not re-screened for mental disorders with a PASARR Level 1 after a 30-day exemption expired, despite continued residence in the facility. The initial PASARR indicated a major mental disorder and the exemption, but no follow-up screening was completed as required by facility policy.
A resident with significant medical and cognitive conditions, identified as high risk for falls, experienced three unwitnessed falls. The facility failed to complete thorough post-fall investigations as required by policy, including missing documentation, lack of staff statements, and incomplete root cause analysis, resulting in inadequate supervision and failure to implement effective fall prevention interventions.
A resident with multiple health conditions experienced significant unaddressed weight loss, with no evidence of physician or RD notification or new interventions. Over half of the resident's meal intake records were missing, preventing accurate assessment of nutritional status.
A resident reported inappropriate touching by another resident to a physical therapist, who documented the incident and informed a nurse. The nurse did not escalate the report to the NHA or authorities, resulting in a delay of over twelve hours before the incident was properly reported, contrary to facility policy requiring immediate notification of abuse allegations.
A resident with dementia and depression engaged in inappropriate sexual behavior toward another resident, but the facility did not notify the psychiatric provider or provide medically related social services to address the incident. There was also no documentation of care plan updates or attempts to obtain consent for continued psychiatric services from the resident's POA.
The facility failed to secure resident valuables and prevent the misappropriation of money and personal items, with several residents missing cash and identification from a locked office. Additionally, a nurse diverted narcotic medications from a destruction box, and the required background check for this staff member was not on file, despite her history of license suspension and prior incidents of theft and drug diversion. Facility policies for securing valuables and controlled substances were not consistently followed, leading to these deficiencies.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall. Facility policy required prompt notification of the resident's representative, but no documentation of such notification was found. Interviews with the Administrator, DON, and Medical Records confirmed that the representative was not notified as required.
Two residents were not adequately protected from abuse: one was verbally abused by a CNA after spilling food, and another, with dementia, was exposed to potential sexual abuse when another cognitively impaired resident attempted to get into bed with them. The facility did not ensure proper communication or assessment of known resident relationships, contributing to these failures.
The facility did not report allegations of injury of unknown origin, verbal abuse, neglect, and drug diversion to the State Survey Agency within the required timeframe. Incidents involving residents with complex medical conditions and a case of drug diversion by an RN were all reported late, contrary to facility policy requiring immediate notification.
The facility did not complete a thorough investigation or submit timely reports for two residents involved in abuse and neglect allegations. One resident's substantiated verbal abuse case was not reported to the State Agency within the required timeframe, and another resident's neglect investigation lacked interviews with other residents present during the incident.
A resident at moderate risk for falls experienced an unwitnessed fall in her room, with a wardrobe/dresser found on top of her. The facility's investigation focused on the wardrobe's position rather than the circumstances leading to the fall, failing to conduct a root cause analysis. The investigation did not determine when the resident was last assisted with toileting or if staff heard her request for help. Additionally, the facility did not ensure that wardrobe dressers were safely secured to prevent similar incidents.
A resident's missing gold necklace was not reported to the NHA or State Survey Agency within 24 hours, delaying the investigation. The family reported the missing item to an LPN, who left a voicemail for the NHA, but the NHA was not informed until days later. The facility's policy requires immediate reporting and investigation, which did not occur due to a communication breakdown.
Two residents in an LTC facility did not receive necessary care to prevent and manage pressure injuries. One resident's care plan was not followed, leading to extended periods in a wheelchair without repositioning, while another resident's air mattress was not functioning, yet staff documented it as checked and working. These deficiencies highlight lapses in adhering to professional standards for pressure injury prevention and management.
Three residents in an LTC facility experienced multiple falls due to inadequate supervision and failure to implement and update fall prevention interventions. One resident suffered a hip fracture and wrist fractures, while another's care plan was not followed, leading to falls. Investigations were incomplete, lacking root cause analysis and necessary care plan revisions.
The facility failed to adhere to professional food safety standards, affecting 65 residents. Observations included improper food storage, expired milk, structural issues in the kitchen, and staff not wearing beard covers. Additionally, improper storage practices were noted with flour bins and unbaked cookie dough. These issues were acknowledged by the kitchen manager and shared with the facility's administration.
The facility failed to maintain effective infection control practices, as shared glucometers were not cleaned between uses, and a resident's catheter bag was left on the floor. LPNs were observed using the same glucometer on multiple residents without proper disinfection, and a resident reported their catheter bag was not attended to in a timely manner, indicating lapses in adherence to infection control protocols.
The facility failed to report allegations of abuse and a physical altercation involving residents within the required timeframe. In one case, a resident's abuse allegation was reported two days late, allowing the alleged perpetrator to continue working. Another incident involved a family altercation in the dining room, reported late to the Nursing Home Administrator. A third resident's abuse claim was also delayed in reporting due to disbelief and lack of physical evidence.
The facility failed to thoroughly investigate abuse allegations for three residents, including incidents of possible retaliation, family altercations, and forced care. Investigations were incomplete, staff education was lacking, and law enforcement was not always notified. The previous NHA dismissed complaints and did not ensure comprehensive investigations or staff training.
The facility failed to complete necessary PASARR screenings for two residents. One resident remained beyond a 30-day exemption without a revised PASARR, and another resident with Schizophrenia was inaccurately screened, missing a required Level II PASARR. Errors by admissions staff and procedural lapses contributed to these deficiencies.
Three residents in the facility did not have comprehensive care plans addressing their specific health needs. One resident on continuous oxygen lacked a respiratory care plan, another with bowel issues had no bowel monitoring plan, and a third with incontinence had no care plan for managing toileting. The Director of Nursing and MDS Coordinator acknowledged these oversights, attributing them to possible oversight and frequent hospitalizations.
A resident with chronic abdominal issues and on multiple bowel medications was not adequately monitored by the facility. Despite the facility's policy requiring regular assessment of continence, there was no documentation of bowel monitoring or a care plan for bowel management. Discrepancies were noted between the resident's ADL care plan and CNA worksheet regarding continence status, and staff interviews revealed inconsistent documentation practices.
A facility failed to comprehensively assess and manage a resident's urinary incontinence, leading to a lack of appropriate treatment and services. Despite the resident's cognitive intactness and documented changes in continence status, no comprehensive assessments or care plans were initiated. Staff interviews revealed a lack of documentation and communication regarding the resident's incontinence care needs, contributing to ongoing issues and risk for complications.
A resident experienced significant weight fluctuations that were not properly identified or addressed by the facility. Despite policies requiring notification of significant weight changes to the dietician and physician, there was no evidence of such notifications. Discrepancies between weights recorded in the EHR and dialysis forms were not questioned, leading to a lack of appropriate nutritional interventions.
A resident with malignant pleural effusion and atrial fibrillation did not receive appropriate respiratory care as their oxygen tubing and humidification were unlabeled and undated, and the humidification water level was inadequate. The resident's oxygen was set at 3L/min, contrary to the physician's order of 2L/min as needed. There was no documentation of the resident's vital signs or a respiratory care plan, and the facility's policy on oxygen administration was not followed.
A facility failed to provide adequate care and monitoring for three residents, leading to significant health declines. One resident, admitted with chronic kidney disease and anemia, did not receive necessary lab work, daily weight monitoring, or a nephrology follow-up, resulting in a severe health decline and death. Another resident with edema had no care plan or monitoring, and a third resident did not have all required stool samples collected or a colonoscopy scheduled.
The facility did not conduct annual performance reviews for CNAs, affecting their ability to assess skills competency and provide necessary training. This deficiency involved five CNAs, with no documented reviews since their hire dates. The DON confirmed the lack of reviews, and the facility had no policy for annual performance reviews, potentially impacting care for all 72 residents.
The facility failed to provide required annual Resident Rights training to several staff members, including dietary staff and CNAs, since their hire dates. Despite having a training schedule that included this as a required topic, there was no documentation to confirm completion. The DON confirmed the lack of training records and the absence of a specific training coordinator, highlighting a gap in oversight. This deficiency had the potential to impact all 72 residents in the facility.
The facility failed to provide mandatory annual QAPI training to several staff members, including a PT, a dietary staff member, an RN, and multiple CNAs. The Director of Nursing confirmed the absence of documented training and acknowledged the lack of a specific training coordinator. This deficiency had the potential to impact all 72 residents in the facility.
The facility failed to provide mandatory Infection Control training to several staff members, including a PT, a Dietary staff member, and multiple CNAs, as required by their Infection Control Program. The DON confirmed the lack of documentation and acknowledged the absence of a specific training coordinator, resulting in the oversight.
The facility failed to provide required annual Compliance and Ethics training to staff, including a PT, DIET, RN, and several CNAs, potentially affecting all 72 residents. The facility lacked a policy for this training, and the 2023 training schedule did not include it. The DON confirmed the absence of training documentation and acknowledged the lack of a specific training coordinator.
The facility failed to provide required annual Behavioral Health training to several staff members, including a PT, DIET, RN, and multiple CNAs. The facility's assessment and training schedule did not include Behavioral Health as a required topic, and the DON confirmed the absence of documented training. Despite being informed of the issue, no additional information was provided to demonstrate compliance.
The facility failed to maintain the confidentiality of resident information, as report sheets and CNA worksheets containing personal details were left unattended in a dining area. These documents included names, physician details, and care requirements, and were observed multiple times without staff present to secure them. The issue was acknowledged by the ADON, but no explanation was provided for the breach.
The facility failed to maintain an effective training program for staff, lacking documentation and formal procedures for required training. Eight staff members, including a PT, DIET, RN, and CNAs, were affected. The DON confirmed the absence of a formal program and training coordinator, and the facility could not provide evidence of completed trainings.
Failure to Provide Timely Incontinence Care and Report Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect and to ensure timely incontinence care, as well as failure to recognize and act on an allegation of neglect as abuse under its own policy. The resident, cognitively intact and frequently incontinent of urine, required substantial/maximal assistance for toileting hygiene, bathing, and transfers, and had a care plan intervention to clean the peri-area with each incontinence episode. The resident reported that on a day in January or February, a CNA (CNA‑Q) woke the resident abruptly, commented that the resident had an attitude and was rude, and then failed to provide requested incontinence care for the remainder of the day shift. The resident stated that first‑shift staff typically changed the incontinence brief after breakfast and again early afternoon, but on this day CNA‑Q did not change the brief after breakfast, ignored repeated requests at lunch to be changed and toileted, and left the room without responding. According to the resident’s account to the surveyor and to staff, the resident remained in a urine‑soaked brief and bed linens throughout the day, became cold, wet, dirty, and itchy in the genital area, and repeatedly used the call light without receiving care from CNA‑Q. The resident described feeling like garbage and useless, stated that the situation made the resident feel awful, and tearfully characterized the experience as severe physical abuse. When second‑shift CNA‑G arrived, CNA‑G found the resident’s bed linens and incontinence brief soaked with urine, provided a full bed bath, changed the brief, cleaned the mattress, and remade the bed. CNA‑G reported the incident to the ADON and social worker. The facility’s abuse/neglect policy defines neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and includes failure to provide care needs such as comfort, safety, and bathing as possible indicators of abuse, yet the resident’s description of prolonged lack of incontinence care and emotional impact was not treated as an abuse/neglect allegation in accordance with policy. Multiple staff members had knowledge of the resident’s allegation and observations consistent with neglect, but the facility did not ensure appropriate reporting, documentation, or investigation at the time of the event. CNA‑G told the surveyor that CNA‑Q admitted during shift report that the resident kept asking to be changed and that CNA‑Q said she would return but did not. CNA‑G stated the resident was in tears and upset and that ADON‑E and SW‑R were informed. ADON‑E confirmed that the resident reported not being changed for an entire shift, was crying, and required consoling, and stated that a grievance was initiated and given to social services. However, there were no progress notes documenting the incident, no self‑report to the state agency, and no grievance on the grievance log initially provided to the surveyor. When interviewed, SW‑R and SW‑P reported they were not aware of the concern and could not locate a related grievance. The NHA stated that staff are expected to report allegations of abuse or neglect directly to the NHA, but the NHA was not notified of this allegation despite it being known by multiple staff. Later‑produced records showed a handwritten grievance form completed by SW‑R describing the resident’s complaint that CNA‑Q did not toilet or change the resident during the 6–2 shift and that another CNA on second shift had to change sheets, clothing, and clean the resident, but this grievance had no documented investigation, follow‑up, or resolution. The surveyor determined that the facility failed to protect the resident from abuse and neglect by not intervening to stop the deprivation of care and not ensuring timely incontinence care, and that the lack of investigation and resolution left the effects of the abuse and neglect unaddressed. The resident’s medical and psychosocial background was also documented in the record. The resident had polyneuropathy, type 2 diabetes, COPD, heart failure, and osteoarthritis, and had been assessed as cognitively intact and able to express needs and understand others. Psychiatric evaluations shortly before and after the incident documented major depressive disorder, recurrent, mild, with irritability and complaints about the living situation, and noted that antidepressant medication was recommended but refused by the resident. A PHQ‑9 mood assessment before and after the event showed minimal or no depression scores. Approximately two months after the incident, during the survey interview, the resident continued to vividly describe the event and became tearful and emotional when recounting feeling like garbage, useless, and severely abused while lying in urine‑soaked linens for an entire shift.
Failure to Ensure Safe Medication Administration and Unauthorized Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and safe medication administration for one cognitively intact resident with diagnoses including diabetes, autoimmune thyroiditis, hypertension, chronic kidney disease, dementia, and depression. Facility policy required that medications be administered by licensed nurses or other authorized staff as ordered, in accordance with professional standards, and that staff observe the resident consuming the medication unless otherwise specified in the order. The resident had a physician’s order for an evening dose of cholecalciferol 1000 units by mouth for chronic kidney disease supplementation, but there was no physician order, assessment, or care plan authorizing self-administration of medications. During an observed medication pass, a medication technician prepared the resident’s cholecalciferol by crushing the tablet, mixing it with applesauce in a medication cup, and bringing it to the resident’s room. The technician placed the medication cup and a glass of water on the bedside table, informed the resident that the medication was present, and then left the room without observing the resident take the medication. When questioned, the technician stated that the resident could take the medication independently and that the technician did not stay until medications were consumed if the resident was “with it.” Subsequent observations showed the medication and applesauce still on the bedside table and not consumed. Interviews with an LPN and the DON confirmed that staff should not leave medications at the bedside unless there is a physician order and a completed self-administration assessment and care plan, none of which were present for this resident.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and fully investigate and resolve resident grievances. The facility’s policy requires a designated Grievance Officer to oversee the process, ensure all grievances receive immediate priority, investigate within seven days, and provide the resident or representative with information on who investigated, the steps taken, and the outcome. Surveyors found that for two cognitively intact residents, grievances were not properly investigated, documented, or communicated back to the residents or their representatives, despite the policy requirements. One resident, admitted with multiple diagnoses including severe protein-calorie malnutrition, chronic kidney disease, and dementia but assessed as cognitively intact with a BIMS score of 15, had a grievance filed by a representative alleging that no incontinence care was provided on a specific day shift. The grievance log only documented that the DON observed the resident as dry, with no further documentation of interviews with the resident or assigned staff, no clear investigation steps, and no statement confirming or not confirming the allegation. The grievance form also contained conflicting dates, with the grievance reported on one date but marked as resolved the day before, and there was no documentation that the resident or representative was informed of any resolution or actions taken. Another resident, also cognitively intact with a BIMS score of 14 and admitted with conditions including protein-calorie malnutrition, type 2 diabetes, hemiplegia, Parkinson’s disease, and peripheral vascular disease, filed a grievance stating that a lunch tray was served with a fly on it and that a salad was not being provided with lunch. The grievance record only noted that the Dietary Manager discussed the concern about the salad, with no documentation addressing the fly in the food. The Dietary Manager later documented receiving the concern from a social worker and speaking with dietary staff, but incorrectly stated that the resident was discharged the next day, when in fact the resident remained for several more days. The Maintenance Director reported not being informed of any fly issue. The Nursing Home Administrator, who serves as Grievance Officer, stated that if a department manager reports a grievance as addressed, no further review is completed, and surveyors confirmed there was no documentation of completed investigations, resolutions, or communication of outcomes to the residents for these grievances.
Failure to Timely Report and Investigate Alleged Neglect and Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse or neglect were immediately reported to the Administrator and the State Agency, and that an allegation of neglect was properly documented and investigated. One resident, who is cognitively intact and frequently incontinent of urine, reported that on a day in January or February an unidentified CNA refused to provide incontinence care for an entire day shift despite multiple requests. The resident stated that she typically has her incontinence brief changed after breakfast and again early afternoon, but on this day the CNA did not change her after breakfast, ignored her request at lunch, and left the room without speaking. The resident reported feeling like “garbage” and “useless,” was cold because her brief and bed sheets were soaked with urine, and described being “wet and dirty and itchy where a lady shouldn’t be itchy.” She told the surveyor that she considered this incident to be severe physical abuse, and her description met the facility’s own policy definition of neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. According to interviews, the second-shift CNA who came on duty that afternoon found the resident’s bed linens and incontinence brief soaked with urine, cleaned and changed the resident, and reported the situation to the ADON and a social worker. The ADON recalled that the resident was crying, needed consoling, and that a grievance was initiated and given to the social workers. The resident also reported that she spoke with both the ADON and a social worker about the incident and that she did not see the involved CNA again. However, there were no progress notes documenting the incident, no self-report to the State Agency, and no entry for this event on the grievance log initially provided to surveyors. When first interviewed, the social worker named by the resident and staff stated that nothing about such an incident “was jumping” into her head, that she did not remember anything, and that she could not find any related grievance in the last several months. Additional documentation later produced by the facility included a handwritten grievance form dated the day after the incident, completed by the same social worker who initially denied recollection. This grievance recorded that the resident had asked the CNA to be changed after breakfast, was told the CNA would return, and later put on her call light after 1 p.m. when she still had not been toileted or changed. Another CNA answered the light, said she would get the assigned CNA, and the resident reported that the assigned CNA turned the call light off without providing care. The grievance documented that the second-shift CNA eventually answered the call light, found the resident unchanged from first shift, and then changed the resident’s sheets, assisted her to the commode, and cleaned and changed her clothing. The grievance form contained no documentation of investigation, follow-up, or resolution, and it had not been included on the grievance log given to surveyors. The Administrator stated that staff are expected to notify the Administrator immediately of any allegation of abuse or neglect and confirmed that the described conduct would be considered an allegation of abuse or neglect, yet the Administrator was unaware of this allegation and it was never reported to the State Agency. A second resident also reported an allegation of abuse that was not immediately reported to the Administrator or the State Agency, further demonstrating that not all alleged violations were reported as required by facility policy and regulation. The facility’s own abuse, neglect, and exploitation policy required immediate investigation when suspicion or reports of abuse or neglect occur, written procedures for reporting all alleged violations to the Administrator and State Agency within specified timeframes, and documentation of analysis and follow-up actions. Staff interviews showed inconsistent understanding of reporting expectations: one of three interviewed staff stated they would report an allegation directly to the Administrator, while others indicated they would only inform a nurse or unit manager. Despite multiple staff members (the second-shift CNA, the ADON, and at least one social worker) being aware of the resident’s allegation that her basic toileting and incontinence care needs were refused for an entire shift, the allegation was not promptly brought to the Administrator’s attention, was not self-reported to the State Agency, and was not properly logged and investigated through the facility’s grievance process. These actions and inactions led to the cited deficiency for failure to timely report and investigate alleged abuse/neglect and to report results to proper authorities for the residents involved.
Failure to Investigate and Document Abuse and Neglect Allegations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all allegations of abuse or neglect were immediately reported and thoroughly investigated, as required by its abuse, neglect, and exploitation policy. The policy states that any suspicion or report of abuse or neglect warrants an immediate investigation, including identifying responsible staff, interviewing all involved persons, and providing complete documentation. It also requires that residents be protected from physical and psychosocial harm during and after investigations. In the cases of two residents, these procedures were not followed, and allegations were not promptly reported to the Nursing Home Administrator (NHA) or fully investigated. For one resident, who was cognitively intact and required substantial assistance with toileting, bathing, and transfers and was frequently incontinent of urine, an incident occurred in which a CNA allegedly failed to provide incontinence care for an entire shift. The resident reported that after oversleeping, a CNA woke the resident roughly, made negative comments, and then did not return to change the resident’s incontinence brief after breakfast despite repeated requests. The resident stated that the CNA returned at lunch, placed the lunch tray down without speaking, ignored further pleas to be changed, and left the room. The resident reported remaining in a soaked brief and wet bed until second shift, when another CNA entered, found the resident wet and tearful, stripped the bed, cleaned the mattress, provided a full bed bath, and changed the brief. The resident described feeling cold, wet, dirty, itchy, and emotionally distressed, and characterized the experience as severe abuse. This CNA reported the situation to the Assistant DON (ADON) and a social worker. Despite the resident’s report to multiple staff members, there was no progress note documenting the incident, no self-report to the state, and no entry on the grievance log initially provided to surveyors. The ADON acknowledged recalling the incident and stated that a grievance had been filled out and given to social services, but did not notify the NHA so that an investigation could be initiated. The social worker initially told surveyors there was no recollection or documentation of such a grievance. Later, the facility produced a handwritten grievance form completed by the social worker, detailing that the CNA had not changed or toileted the resident during the shift despite multiple requests and that another CNA ultimately changed the resident’s sheets, clothing, and brief. The grievance form contained no documentation of who investigated, no follow-up, and no resolution, and it was not on the facility’s grievance log. The NHA confirmed not having been informed of this allegation, despite facility expectations that such concerns be reported directly to the NHA. In a second case, another resident with moderately impaired decision-making, a history of intracerebral hemorrhage, diabetes, depression, Alzheimer’s disease, and vascular dementia reported an allegation of abuse involving a CNA. One CNA stated that the resident had reported being afraid of a specific CNA, describing that CNA as mean and aggressive and alleging that the CNA had thrown a breakfast tray at the resident. Another CNA reported that on a specific Sunday, the resident said this CNA was very rough with morning cares, that the resident felt abused, and that the CNA had thrown the breakfast tray. This CNA reported the allegation to an LPN the same day and, the following day, relayed the concerns again to a social worker, including that the resident did not feel safe and remained afraid of the CNA. The resident later confirmed to the surveyor that there had been an incident where the CNA threw the breakfast tray and spoke in a mean tone, and stated that no one came to talk about the incident. The social worker acknowledged being informed about the CNA being aggressive and ripping covers off and stated that the DON and NHA were informed and that a grievance was entered, but did not write a statement after interviewing the resident and was not aware of the tray-throwing allegation at that time. The social worker further stated that learning of the tray incident later was not reported to the NHA or DON due to competing demands and the absence of a morning meeting. The NHA, who is the grievance officer and responsible for abuse and neglect investigations, did not recall being told about the abuse allegation involving this resident, and the grievance log contained no entry for this resident on the relevant date. The NHA agreed that a thorough investigation should have begun when the allegation was first reported to nursing staff, but there was no evidence that such an investigation was initiated at that time, and the CNA continued providing care without a completed investigation. Across both residents’ cases, multiple staff members (CNAs, ADON, and social workers) received direct reports of alleged neglect or abuse but did not consistently notify the NHA as required, did not ensure that grievances were logged, and did not complete or document thorough investigations. The facility’s own abuse and neglect policy requiring immediate investigation, identification and interviewing of all involved persons, and complete documentation was not followed. As a result, the allegations were not promptly or fully investigated, and documentation such as progress notes, grievance log entries, and investigation records were missing or incomplete for both residents’ reported incidents.
Moldy Fruit and Flies on Meal Trays Compromise Food Palatability and Safety
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was palatable, attractive, and safe, as required by its food storage policy stating that sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. One resident, admitted with multiple diagnoses including severe protein-calorie malnutrition, chronic kidney disease, and dementia but assessed as cognitively intact and independent with eating, was served a bowl of peaches that appeared to have white fuzzy and green fungal mold. A photograph of the peaches, taken by the resident and sent to an anonymous individual, showed the apparent mold, and an LPN later confirmed observing white fuzzy mold and green fungi on the peaches when the tray was delivered and immediately removed the peaches from the tray, stating it was horrible to put such food on a resident’s tray. The same resident also had a meal tray with mixed vegetables on which a fly was observed, as documented in another photograph taken by the resident and reviewed by the surveyor. The resident routinely photographed every meal and sent the images to the anonymous individual, who then shared them with the surveyor. When interviewed, the Nursing Home Administrator stated not recalling being informed about mold or flies on the resident’s food, even after the surveyor presented concerns that the resident had been served food that was not attractive and palatable. A second resident, also cognitively intact and admitted with conditions including unspecified protein-calorie malnutrition, type 2 diabetes mellitus, hemiplegia/hemiparesis following cerebral infarction, Parkinson’s disease, peripheral vascular disease, and atherosclerotic heart disease, filed a grievance stating they received a lunch tray with a fly on it. The grievance record showed that the Dietary Manager discussed the concern with the resident but did not document addressing the issue of the fly itself. In an interview, the Dietary Manager stated being unable to speak with the resident because they believed the resident was discharged the next day, although records showed the resident remained for several more days. The Dietary Manager acknowledged the possibility of flies due to the steam table’s proximity to an outside door. The Maintenance Director reported not being informed of any fly issue and noted that pest control only addresses specific concerns when notified. The Nursing Home Administrator did not recall being informed about flies on food for this resident either, while the surveyor noted that the resident had been served food that was not attractive and palatable.
Failure to Hold and Document Required Quarterly Care Plan Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were able to participate in the development and implementation of their person-centered plans of care through required quarterly care plan conferences. Facility policy dated 1/5/25 states that care plan review/conference will be conducted at least quarterly, be interdisciplinary, and provide an opportunity for resident and family discussion and input. For one resident admitted with cervical radiculopathy, adult failure to thrive, pulmonary hypertension, and depression, with a BIMS score of 15 indicating intact cognition, there was no documentation of any quarterly care conference from mid-2025 through early 2026. The resident reported that care conferences had been scheduled in April and July but that no one showed up, and that nothing had been scheduled since July. Review of the medical record and progress notes from 6/17/25 to 2/3/26 revealed no evidence of a quarterly care conference, and both the Social Services Designee and Director of Social Services confirmed they could not identify any such conference for this resident. A second resident, admitted with palliative care needs, chronic lymphocytic leukemia, heart failure, and COPD, had a quarterly MDS showing severe cognitive impairment with a BIMS of 7 and functional limitations requiring assistance with mobility, hygiene, eating setup, showering, bed mobility, and transfers. Review of this resident’s progress notes and medical record on 2/3/26 showed no documentation of any care conferences. The social worker responsible for care conferences and admissions stated that no care conferences had been completed for this resident to their knowledge and that they had not conducted any for this resident. The social worker was unable to provide any emails or notes indicating that care conferences had occurred. When interviewed, the resident did not recall any care conferences since admission and stated that family usually handled care discussions but had not mentioned any conferences recently. A third resident, readmitted with Alzheimer’s disease, type II diabetes mellitus, dementia, and anxiety disorder, was described by staff as confused and speaking only a non-English language. Review of this resident’s medical record showed no evidence of any care conference in the previous twelve months while the resident resided full time at the facility. The social worker responsible for care conferences and admissions stated that, to their knowledge, no care conferences had been completed for this resident and confirmed they had not conducted any. They were unable to provide any supporting documentation such as emails or notes about care conferences. When these findings were presented to facility leadership, including the DON, NHA, and Director of Operations, no additional information was provided to explain the absence of required care conferences for these residents.
Failure to Timely Report Resident’s Allegation of Staff Mistreatment
Penalty
Summary
The facility failed to report a resident’s allegation of potential abuse to the State survey agency and the Nursing Home Administrator within the timeframes required by its abuse, neglect, and exploitation policy. The policy, last reviewed on 11/5/25, requires all alleged violations to be reported to the Administrator, State agency, adult protective services, and other required agencies within 2 hours if the allegation involves abuse or serious bodily injury, or within 24 hours if it does not. On 1/1/26 at 6:12 a.m., an RN documented that the resident requested to see the nurse during the night shift and complained about two night-shift CNAs who performed ADL care, stating he wanted the matter reported. The RN notified the DON and obtained CNA statements, but there is no documentation that the allegation was reported to the State agency or the Nursing Home Administrator. The resident involved had diagnoses including cervical radiculopathy, benign prostatic hyperplasia, adult failure to thrive, pulmonary hypertension, and depression, and was cognitively intact with a BIMS score of 15. The MDS documented that the resident was dependent on staff for toileting hygiene and transfers, required substantial/maximal assistance for rolling, and was always incontinent of urine with a colostomy. During an interview with the Surveyor, the resident described an incident on New Year’s Day in which two female staff insisted on changing him despite his statement that he was not wet, and he alleged that one staff member held his wrists and pulled him, hurting his shoulder, while the other removed his brief. He reported telling the nurse that staff had “roughed him up” and that something had to be done, and confirmed he told the nurse that his wrists were held down. The RN later confirmed to the Surveyor that the resident complained about how staff were trying to change him and wanted to make a report, and that this was reported to the DON. The NHA stated she was not notified of the allegation and confirmed there had been no facility-reported incidents to the State agency for this resident in the last six months.
Failure to Thoroughly Investigate Resident Allegation of Rough Care by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of mistreatment as required by its abuse, neglect, and exploitation policy. The policy, last reviewed on 11/5/25, requires an immediate investigation of any suspicion or report of abuse, neglect, or exploitation, including identifying and interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge) and providing complete documentation. Despite this, the facility did not conduct a comprehensive investigation after a resident reported concerns about how two CNAs provided ADL care, and the facility did not interview any other residents to determine if there were broader concerns about care. The resident involved had diagnoses including cervical radiculopathy, benign prostatic hyperplasia, adult failure to thrive, pulmonary hypertension, and depression, and was cognitively intact with a BIMS score of 15. He was dependent on toileting hygiene and transfers, required substantial/maximal assistance for rolling, was always incontinent of urine, and had a colostomy. On New Year’s Day, he reported to the Surveyor that two female staff entered his room around 2:00 a.m. to change him; he stated he told them he was not wet, but they insisted on changing him, that one staff member held his wrists and pulled him, hurting his shoulder, while the other removed his brief, and that he told them he did not have dementia and did not need this care. He further stated he reported to the nurse that staff had “roughed him up” and held his wrists down, and that the nurse did not respond. A nurse’s note dated 1/1/26 at 06:12 by an RN documented that the resident wanted to see the nurse during the night shift, complained about the two night CNAs who performed ADL care, and wanted the issue reported. The RN notified the DON and was authorized to have the CNAs write statements, which were placed under the DON’s door. In interviews, the RN confirmed he reported the incident to the DON. The DON acknowledged being notified that the resident did not want to be changed and that she had CNA statements, and described the situation as the resident becoming belligerent, striking out at staff, and refusing care. However, the DON stated she did not talk to the resident, did not conduct an investigation, did not interview the CNAs beyond obtaining their written statements, and did not obtain a statement from the RN. The NHA also reported not conducting any investigation. As a result, the facility lacked evidence of a thorough investigation of the resident’s allegation, and no resident interviews were conducted to identify any additional concerns about care.
Failure to Develop Person-Centered Baseline Care Plan on Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered baseline care plan within 48 hours of admission for a newly admitted resident. Facility policy required that a baseline care plan be developed within 48 hours of admission, including minimum healthcare information such as initial goals based on admission orders, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable. The policy also required that the admitting or supervising nurse gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative, then establish goals and interventions reflecting the resident’s stated goals and current needs, and that a supervising nurse verify within 48 hours that a baseline care plan had been developed. For this resident, the baseline care plan that was created did not contain specific, person-centered interventions and did not fully reflect the resident’s identified needs and hospital discharge instructions. The resident was admitted with multiple diagnoses, including a wedge compression fracture of the second thoracic vertebra, bilateral pneumonia, type 2 diabetes mellitus, essential hypertension, chronic heart failure, Alzheimer’s disease, and dementia. The 5-day admission MDS documented a BIMS score of 4, indicating severely impaired decision-making, and showed that the resident required varying levels of assistance with ADLs, was always incontinent of bowel and bladder, was at risk for pressure injuries, and was on a mechanically altered diet. Hospital discharge documentation indicated the resident needed a TLSO brace, a puree/thin diet with no straws, small sips, upright positioning, 1:1 supervision, and medications crushed in puree. Hospital therapy notes documented that the resident was unable to complete self-care and functional mobility sufficient to return to the prior living situation, required alarms for safety, and needed moderate assistance for functional mobility with identified deficits in ADLs, mobility, cognition, safety awareness, and sequencing. Despite these identified needs, the facility’s baseline care plan and CNA Kardex contained generic, incomplete, and non–person-centered interventions. The baseline care plan listed problems such as diabetes, oxygen use, pain, psychotropic medication use, fall risk, potential/actual skin integrity impairment, bowel and bladder incontinence, ADL self-care deficits, limited physical mobility, and a desire to discharge home, but many interventions were left blank or written in non-specific terms (e.g., “specify what assistance,” “specify frequency,” “provide pressure relieving device(s): (specify)”). The care plan did not document the need for 1:1 supervision, the pureed diet with no straws, or other specific hospital discharge instructions. Fall interventions were limited to generic measures such as keeping the call light within reach, educating about safety, and following facility fall protocol, without individualized strategies similar to the hospital’s use of bed and chair alarms. The Kardex, which CNAs relied on for daily care, mirrored these incomplete and non-specific interventions and did not include detailed fall-prevention or aspiration-prevention measures. During interviews, the DON acknowledged that the baseline care plan and Kardex were not specific and that staff would not have known how to care for the resident to keep the resident safe and support the highest level of independence.
Failure to Complete Neurological Checks per Policy After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete and document neurological assessments according to its own policy and procedure following unwitnessed falls for one resident. The facility’s Neurological Assessment policy, effective 5/19/22, requires neuro checks after head injuries or when indicated for a change in condition, including unwitnessed falls, with assessments of level of consciousness, speech, pupils, hand grasps, and vital signs. Unless otherwise ordered, the policy specifies a schedule of Q15 minutes × 1 hour, Q1 hour × 4 hours, then Q shift × 72 hours. The DON stated that the expectation is 4 fifteen‑minute checks, 4 one‑hour checks, and 4 eight‑hour checks, all documented in the electronic medical record. The resident involved had multiple diagnoses including wedge compression fracture of the second thoracic vertebra, fall history, pneumonia, type 2 DM, essential HTN, chronic heart failure, Alzheimer’s disease, and dementia, and had a BIMS score of 4 indicating severely impaired decision‑making. The resident experienced two unwitnessed falls on the same day, both documented as having no injuries, and the 24‑hour report indicated that neuro checks were initiated after each fall. For the first unwitnessed fall at 4:33 PM, documentation showed 4 fifteen‑minute neuro checks, 2 thirty‑minute checks, and 2 one‑hour checks, with no further checks completed per policy. For the second unwitnessed fall at 8:35 PM, documentation showed 4 fifteen‑minute neuro checks and 1 thirty‑minute check, with no additional checks completed per policy. No explanation was provided as to why the neurological checks were not completed in accordance with the facility’s policy and procedure.
Failure to Provide Adequate Supervision and Person-Centered Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, assistance, and person‑centered fall prevention interventions for residents at high risk for falls, and failure to conduct thorough post‑fall investigations with root cause analyses. One resident was admitted with multiple diagnoses including a history of falls, dementia, Alzheimer’s disease, weakness, impaired mobility, and cognitive deficits. Hospital documentation prior to admission showed this resident required bed and chair alarms and had significant safety‑awareness and functional limitations. On admission, the facility’s fall risk assessment identified the resident as high risk for falls, and PT/OT evaluations documented balance deficits, decreased safety awareness, impaired judgment, and a high risk for further falls without skilled interventions. Despite this, the baseline care plan and Kardex contained generic, incomplete, and non‑person‑centered interventions such as “call light within reach,” “follow facility fall protocol,” and unspecified assistance levels for bed mobility, transfers, ambulation, and ADLs, without clear instructions to staff on how to safely care for the resident. Within approximately 48 hours of admission, this resident experienced three falls. The first two falls on the same day were unwitnessed, and documentation by the LPN noted the resident was found on the floor, assessed as alert and oriented to one, with neuro checks documented and vital signs stable. The resident was assisted back to a wheelchair and placed in common areas for supervision. However, when the surveyor requested the fall investigation for the first unwitnessed fall, the facility could not provide a completed investigation with root cause analysis, and there were no staff statements describing where in the room the resident was found, what the resident had been doing, or other contextual details such as continence status. For the second unwitnessed fall, the facility’s fall investigation form lacked clarity about where the resident had been last seen (bed or chair), how far the resident moved before being found on the floor under a chair, and how the resident sustained a bump to the right side of the head. There were no staff witness statements, and no documented root cause analysis or detailed investigation of contributing factors. The surveyor also noted there was no RN assessment documented after the first fall. The third fall for this resident was a witnessed fall at the nurses’ station, where the resident had been kept under supervision after the earlier events. Nursing documentation described the resident as confused, refusing to sit, fighting and scratching staff, verbally expressing a desire to fall, and pulling out oxygen tubing. The nurse reported that the resident suddenly stood up and fell, sustaining a head laceration that required emergency room evaluation. When the surveyor requested a fall investigation and root cause analysis for this event, the facility again was unable to provide one, and there were no staff statements detailing what specific interventions were attempted to manage the resident’s agitation and maintain safety at the nurses’ station. The DON later acknowledged that there were no person‑centered fall interventions in place for this resident despite the known high fall risk and prior hospital documentation. A second resident, also identified as high risk for falls based on a fall risk assessment, had a care plan that listed only generic interventions such as keeping the call light within reach, ensuring appropriate footwear, and following facility protocol. This resident experienced an unwitnessed fall while getting out of bed. The fall investigation form documented that the resident was found on the floor and that the call light was within reach, but the witness statement indicated, “I didn’t see anything.” The investigation did not include additional staff statements or information about when the resident was last seen or last toileted before the fall. When questioned, the DON confirmed that the facility had no further information regarding the timing of the last observation or toileting. Across both residents, the facility did not complete thorough post‑fall investigations or root cause analyses and did not develop or revise individualized, person‑centered interventions to address identified fall risks.
Failure to Inspect and Document Safety of Beds and Bed Rails per MIFU and FDA Guidance
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document required inspections and safety assessments of resident beds, including bed frames, mattresses, and bed rails or assist/mobility bars. Surveyors observed resident beds with assist/mobility bars in use. During interviews, the Nursing Home Administrator stated there were no bed inspections being conducted and confirmed there was no policy regarding bed inspections. The Maintenance Director reported that when a new admission is anticipated, maintenance staff go to the room, remove safety bars, ensure a mattress is present, inspect the bed, test the remote, and check for exposed wires, and that therapy may later order safety bars or bed extensions or special mattresses. However, the Maintenance Director acknowledged that these inspections are not documented. Review of the Manufacturer’s Instructions for Use (MIFU) for Joerns Model U770, U790, and U795 beds showed that the beds and accessories are to be visually inspected monthly for broken welds, cracks, and loose hardware, and that any bed with such defects must be removed from service and repaired. The facility did not document that these monthly inspections were performed for any of the 77 resident beds. In addition, review of FDA guidance on hospital bed system entrapment risks identified seven potential entrapment zones and recommended dimensional limits for zones 1–4. The Maintenance Director stated that although they have reference sheets describing the seven or eight entrapment zones and related measurements, the facility does not perform or document FDA entrapment safety zone measurements for any of the 36 residents identified as having bed rails, mobility bars, or assist bars.
Failure to Maintain Safe Hot Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to maintain and serve food at safe temperatures in accordance with professional standards and its own food safety policy. A cognitively intact resident with severe protein-calorie malnutrition and multiple comorbidities, including spinal stenosis, history of stroke, COPD, poly-osteoarthritis, and anxiety disorder, reported that the food served was cold and that not all aides would reheat it. During the evening meal observation, the resident consented to have the temperature of her meal checked as it was removed from the transport cart for delivery. The Dietary Manager measured the temperature of the chicken and noodles on the resident’s tray and found it to be 93.7°F as it came off the cart, acknowledging that the last cart had arrived on the floor earlier and that the food was not hot enough. The Dietary Manager stated the need to reheat the food to 165°F. Review of the facility’s Food Safety policy showed that staff are required to monitor food temperatures while holding for delivery and to follow FDA Food Code standards, including reheating cooked and cooled food to 165°F and heating ready-to-eat foods to at least 135°F. Federal guidance cited in the report explains that bacterial growth can occur when food remains in the “Danger Zone” (between 40°F and 140°F/135°F) for too long, and that hot food should be kept at or above 140°F.
Failure to Provide Required Meal Set-Up Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required meal set-up assistance for one resident who needed help with activities of daily living (ADLs). The resident had diagnoses including cerebral infarction, parkinsonism, hemiplegia, and hemiparesis affecting the left non-dominant side, and a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderately impaired cognition. The resident’s quarterly MDS documented a need for assistance with meal setup and cleanup. During a dining room observation, the resident was seated alone with his meal plate still covered in plastic wrap; he had only partially torn the wrap and had not fully removed it, and did not respond when asked if assistance was needed. During the same observation, the Dining Services Manager approached and removed the plastic wrap, stating that the serving staff should have removed it when the meal was served. A CNA later acknowledged that she should have removed the plastic wrap from the resident’s meal tray, although she stated the resident no longer required staff to feed him. The DON stated that CNAs serving meals were required to complete meal setup when indicated, and the Nursing Home Administrator stated that staff were expected to meet all ADL needs, including meal setup and cleanup when indicated. Review of the facility’s ADL policy confirmed that, based on the comprehensive assessment and resident needs, the facility must provide necessary care and services to maintain ADL abilities, including assistance with meal setup.
Failure to Administer Acarbose as Ordered Before Meals
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed medication, acarbose 25 mg, as ordered to a resident with hypoglycemia, diabetes, and diabetic chronic kidney disease. The resident was admitted on 10/17/25 and readmitted on 10/31/25, with an acarbose order dated 11/20/25 for administration by mouth before meals at 7:30 AM, 11:30 AM, and 4:30 PM. Review of the Medication Audit Report for the ordered acarbose doses over multiple days showed repeated late administrations significantly outside the scheduled times, including morning doses given several hours after the ordered time and evening doses given hours late. On one date, two separate scheduled doses (7:30 AM and 11:30 AM) were documented as administered at the same time. The Nursing Home Administrator reported during interview that the facility did not have a policy regarding medication administration. The DON stated the expectation that medications are given as ordered and, upon reviewing the Medication Audit Report, acknowledged that the documented administration times were outside the normal administration leeway and that nurses should document when medications are given outside parameters due to meal delivery time. Reference material from the National Institute for Health indicated that acarbose should be administered three times daily with the first bite of each meal to delay carbohydrate digestion and slow glucose absorption. A message was left with the Medication Technician who worked most of the relevant dates and times, but no return call was received, leaving the late and irregular administration times unexplained.
Failure to Document and Investigate Resident Grievance Regarding Incontinence Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's grievance was formally documented, investigated, and resolved according to the facility's grievance policy. The resident, who was cognitively intact and dependent on staff for mobility and transfers, reported being left on the call light for 4-5 hours while needing incontinence care after their ostomy bag broke, resulting in feces exposure. The resident attempted to get assistance by calling the main facility phone number multiple times, and although several staff responded to the call light, they did not provide the necessary care. The Director of Social Services was notified of the resident's repeated calls and visited the resident's room, but did not initiate a formal grievance or document the concern. The Nursing Home Administrator, who is designated as the facility's grievance official, was aware of the incident but did not gather further details, obtain staff statements, or conduct an investigation. Both the Director of Social Services and the Nursing Home Administrator acknowledged that a formal grievance should have been initiated and investigated, but this was not done. The facility's policy requires that all grievances, including verbal complaints, be documented, investigated, and resolved promptly, with written decisions issued to the resident. In this case, the facility staff did not follow these procedures, resulting in the resident's expressed care concerns not being formally addressed or investigated as required by policy.
Failure to Complete PASARR Screening After 30-Day Exemption Expired
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was accurately screened for a mental disorder prior to the expiration of a 30-day PASARR (Preadmission Screening and Resident Review) exemption. The resident was admitted with diagnoses including anxiety disorder, depression, dementia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and atherosclerotic heart disease. The resident's initial PASARR Level 1 screening indicated a major mental disorder and documented a 30-day hospital discharge exemption. However, after the 30-day exemption expired, no new PASARR Level 1 screening was completed, despite the resident continuing to reside in the facility for over a year. The facility's policy requires a Level 1 PASARR screen for new admissions and specifies that a new screen is not required only if the attending physician certifies the resident will need less than 30 days of nursing facility services. In this case, the admissions department completed the initial PASARR, but the responsibility for subsequent screenings or referrals was assigned to the social services department. The deficiency was identified when it was discovered that the resident's PASARR was not updated after the exemption period, and there was no documentation explaining why the required screening was not completed.
Failure to Complete Thorough Fall Investigations for High-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including hypertensive encephalopathy, hemiplegia, prostate cancer, chronic pulmonary embolism, anemia, gout, dementia, and depression, was identified as being at high risk for falls. The resident experienced three unwitnessed falls within the facility. Despite the facility's policy requiring thorough post-fall investigations, including root cause analysis and staff statements, these procedures were not consistently followed for each incident. For the first two falls, no Post-Fall Investigation Forms were completed, and there was a lack of documentation regarding what the resident was doing prior to the falls, what interventions were in place, and whether those interventions were effective. The third fall had a Post-Fall Investigation Form completed, but it lacked staff statements and did not provide input on interventions to prevent further falls. The absence of thorough investigations prevented the identification of root causes and the implementation of effective fall prevention strategies. Interviews with the DON revealed that prior to their tenure, thorough investigations were not being completed, and although new policies and training were implemented, the required investigative steps were still not followed for these incidents. The facility was unable to provide explanations for the lack of comprehensive investigations for the resident's three falls, resulting in a failure to ensure adequate supervision and accident prevention as required by facility policy.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding significant weight loss. The resident, who had multiple diagnoses including severe protein calorie malnutrition, chronic kidney disease, and legal blindness, experienced a weight loss of 10.1 pounds (6.61%) over three weeks. Despite facility policy requiring notification of the physician or registered dietician (RD) for significant weight changes, there was no evidence that either was notified or that new nutritional interventions were implemented. The resident's care plan identified them as at risk for impaired nutrition, and assessments indicated malnutrition and ongoing weight concerns, but no follow-up documentation or recommendations from the RD were found after the initial assessment. Additionally, the facility failed to maintain adequate documentation of the resident's meal intake, with over half of the meals served lacking any record of consumption. This lack of documentation made it impossible to accurately assess the resident's nutritional intake in relation to the observed weight loss. The surveyor confirmed these findings with facility leadership, who acknowledged the gaps in documentation and monitoring but did not provide further information prior to the survey exit.
Failure to Timely Report Alleged Abuse to Proper Authorities
Penalty
Summary
A deficiency occurred when staff failed to report an allegation of inappropriate touching between residents in a timely manner, as required by facility policy. A resident with intact cognition reported to a physical therapist that another resident had put a hand inside their shorts during lunch. The physical therapist documented the incident on a Stop and Watch form and notified the unit nurse. However, the nurse did not escalate the report to the Nursing Home Administrator (NHA) or other appropriate authorities, instead speaking with the resident and concluding that no further action was needed after the resident denied the incident. This resulted in a delay of at least twelve hours before the NHA was notified and the incident was reported to the state agency. Facility policy required immediate reporting of abuse allegations, but staff failed to follow this protocol. The NHA and Director of Clinical Services confirmed that the Stop and Watch form was not the appropriate method for reporting abuse and that the nurse should have reported the incident immediately. The delay in reporting was attributed to the nurse's decision not to escalate the matter, despite being made aware of the allegation by the physical therapist.
Failure to Provide Necessary Behavioral Health Services After Inappropriate Resident Behavior
Penalty
Summary
The facility failed to ensure that a resident with dementia and depression received necessary behavioral health care and services as required by their comprehensive assessment and care plan. The resident, who had a severe cognitive impairment and a history of depression, exhibited inappropriate sexual behavior towards another resident. Despite this incident being reported to staff and documented, there was no evidence that the psychiatric provider overseeing the resident's care was notified of the behavior. Additionally, there was no documentation that the resident received medically related social services to address or debrief the behavior following the incident. Further review revealed that the facility did not initiate or update a care plan to address the resident's depression or the manifestations of their mental health condition. The psychiatric provider was not kept informed of the resident's behaviors, and there was no documentation that the resident's Power of Attorney was contacted to obtain consent for continued psychiatric services. The lack of communication and documentation resulted in the resident not receiving appropriate behavioral health interventions or follow-up after the incident.
Failure to Protect Resident Property and Prevent Drug Diversion
Penalty
Summary
The facility failed to prevent the misappropriation of resident property for five sampled residents, resulting in missing cash and personal items such as wallets, credit cards, and identification cards. An audit of valuable envelopes stored in the Social Services Director's (SSD) office revealed that several residents were missing various amounts of money, and there was no documentation of reimbursement for the missing funds or for the replacement of a resident's driver's license. The SSD stated that valuables should be kept in a locked box in the medication room, managed by nursing staff, but the missing items were found to have been stored in the SSD office, indicating a lapse in the facility's process for securing resident property. Additionally, the facility failed to ensure the security of controlled substances, resulting in drug diversion by a registered nurse (RN). Video footage showed the RN removing drugs from the narcotic destruction box using a coat hanger and placing the pills in her pockets. The nurse was an agency staff member whose background check was not on file with the facility, and it was later discovered that her nursing license had been suspended due to previous incidents involving theft and drug diversion at other facilities. The facility's contract with the staffing agency required background checks, but there was no evidence that this was completed for the RN in question. The facility's policies required audits of narcotics, secure storage of controlled substances, and background checks for staff with access to medications. However, these procedures were not consistently followed, as evidenced by the lack of a background check for the RN and the ability to access and remove drugs from the destruction box. The failure to follow established protocols led to the loss of resident property and the diversion of narcotic medications.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the representative of a resident who experienced a fall, as required by facility policy. The policy, revised in February 2022, states that the resident, their health care provider, and representative must be promptly notified of any changes in the resident's condition or status, including accidents or incidents resulting in injury. In this case, a resident with severe cognitive impairment and multiple diagnoses, including diabetes mellitus, hyperlipidemia, thyroid disorder, osteoporosis, hip fracture, and seizure disorder, experienced an unwitnessed fall. The resident was found on the floor, alert and giggling, but unable to recall how the fall occurred. Upon review, there was no documentation found to confirm that the resident's representative was notified of the fall. Interviews with the Administrator, DON, and Medical Records confirmed that notification to the representative could not be located. The Administrator stated that it was her expectation that family representatives, case workers, and physicians be notified of any falls, but in this instance, there was no evidence that such notification occurred.
Failure to Protect Residents from Verbal and Potential Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and potential abuse. In the first instance, a resident with a history of polyneuropathy, rheumatoid arthritis, depression, and anxiety, and who was cognitively intact, reported being verbally abused by a CNA. The resident stated that after spilling food in the dining room, the CNA hit her hand and yelled at her, later telling her, 'I'll be watching you,' which made the resident fearful. Staff interviews confirmed that the CNA yelled at the resident, though no one witnessed physical contact. The CNA had a history of confrontational behavior and had been previously counseled. In the second instance, a resident with dementia and impaired decision-making was not protected from potential sexual abuse by another resident with moderate cognitive impairment. The incident involved one resident attempting to get into bed with the other, resulting in a fall. The investigation revealed that the two residents had a known friendship, but there was no documentation that the interdisciplinary team had been informed or that assessments and interventions were initiated prior to the incident. The lack of proactive measures contributed to the failure to protect the resident from potential abuse.
Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, and injury of unknown origin to the State Survey Agency (SSA) as required by its own policy, which mandates immediate reporting but not later than two hours. Specifically, an incident involving a resident with Alzheimer's, congestive heart failure, and chronic kidney disease who sustained skin tears to her right hand was not reported to the SSA until over a month after the event. Another case involved a resident with polyneuropathy, rheumatoid arthritis, depression, and anxiety who reported verbal abuse by a CNA, but the incident was not reported to the SSA until a week later. Additionally, a resident with a femur fracture, right knee contracture, and lymphedema experienced neglect when care was not provided, and this was not reported to the SSA until several days after the incident. The report also documents an incident of misappropriation of property involving drug diversion by an RN, which was discovered via video surveillance and reported to the SSA the following day. During an interview, the facility administrator confirmed that the expectation is for immediate reporting of abuse, neglect, and injuries of unknown origin, with investigations to be completed within five days or updates provided to the SSA if not complete. The documented delays in reporting these incidents represent a failure to comply with both facility policy and regulatory requirements.
Failure to Complete Abuse and Neglect Investigations and Timely Reporting
Penalty
Summary
The facility failed to ensure a thorough investigation and timely reporting of alleged abuse and neglect involving two residents. For one resident with diagnoses including polyneuropathy, rheumatoid arthritis, depression, and anxiety, the facility did not submit the required five-day report to the State Agency detailing the outcome of a substantiated verbal abuse incident by a Certified Nursing Assistant. This omission was identified through a review of the Facility Related Incident documentation and the facility's own policy, which mandates timely reporting of such incidents. For another resident admitted with a femur fracture, knee contracture, and lymphedema, the facility did not complete a comprehensive investigation into an allegation of neglect. Specifically, the investigation failed to include interviews with other residents present during the night in question, as required by facility policy. The Administrator confirmed that the expectation is for a complete investigation, including interviews and record review, but this was not carried out in this case.
Failure to Investigate Fall and Secure Furniture
Penalty
Summary
The facility failed to thoroughly investigate and identify the root cause of a fall involving a resident, who was at moderate risk for falls. The resident experienced an unwitnessed fall in her room, where she was found with a wardrobe/dresser on top of her. The resident reported losing her balance while attempting to go to the bathroom after calling for help and receiving no response. The facility's investigation focused primarily on the wardrobe's position rather than the circumstances leading to the fall. The facility's falls policy requires a comprehensive evaluation of the area where a fall occurred to identify potential contributors. However, the investigation did not include a root cause analysis of why the resident attempted to toilet herself after requesting assistance. The investigation also failed to determine when the resident was last assisted with toileting or if staff heard her request for help. Additionally, there were conflicting statements from staff regarding the resident's seating position before the fall, which was not resolved in the investigation. The facility did not ensure that the wardrobe dressers used by residents were safely secured to prevent similar incidents. The investigation did not include checking the condition of other dressers/wardrobes in resident rooms, despite the potential safety concern. The facility's focus on whether the dresser had fallen on the resident detracted from addressing the actual fall's cause and ensuring the safety of other residents with similar furniture.
Failure to Timely Report and Investigate Missing Resident Property
Penalty
Summary
The facility failed to report a potential misappropriation of property involving a resident's missing gold necklace to the State Survey Agency or the Nursing Home Administrator (NHA) within the required 24-hour timeframe. The incident was initially reported by the resident's family to a facility staff member on November 29, 2024, but the NHA was not informed until December 2, 2024. Consequently, the investigation into the missing necklace did not commence until December 2, 2024, which was a delay from the initial report date. The facility's policy mandates that all reports of misappropriation of resident property should be promptly reported and thoroughly investigated. However, in this case, the Licensed Practical Nurse (LPN) who received the report from the family left a voicemail for the NHA and a note for the social worker, but the NHA did not receive this information in a timely manner. The Executive Director confirmed that the facility's procedure requires immediate reporting and investigation, which did not occur in this instance. The delay was attributed to a communication breakdown, possibly due to the presence of agency staff, as noted by the NHA.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and promote healing for two residents, R5 and R48. R5, who has a history of a sacral stage 4 pressure injury, was noted to have a new area of concern on 4/16/2024, which was not comprehensively assessed or addressed in the care plan until two days later. Despite being assessed as high risk for pressure injuries, R5's care plan was not followed, as observed by the surveyor on multiple occasions, with R5 remaining in a Broda wheelchair for extended periods instead of being repositioned or laid down as required for pressure injury healing. R48, who was assessed as a moderate risk for pressure injury development, was observed with a non-functioning air mattress on multiple occasions. The air mattress, intended to reduce pressure and prevent pressure injuries, was not plugged in properly, yet staff were initialing that it was checked and functioning correctly every shift. This oversight indicates a failure to ensure that R48 received the necessary treatment and services consistent with professional standards of practice. The facility's policy on pressure injury assessment and treatment emphasizes the importance of consistent identification and care of pressure injuries, yet the facility did not adhere to these guidelines. The lack of timely assessment and care plan revisions for R5, along with the failure to ensure R48's air mattress was functioning, demonstrate significant lapses in care that could contribute to the development and worsening of pressure injuries.
Inadequate Fall Prevention and Investigation in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for three residents, leading to multiple incidents of falls and injuries. Resident R38 experienced several falls, including one that resulted in a hip fracture and another that led to wrist fractures. The facility did not conduct thorough investigations to determine the root causes of these falls, and the care plan was not consistently updated with appropriate interventions. Despite having severe cognitive impairment, R38 was repeatedly reeducated on call light use, which was not a suitable intervention. Resident R29 also experienced falls due to inadequate implementation of fall prevention interventions. The resident's care plan required the wheelchair to be placed next to the bed to facilitate safe transfers, but this was not followed, leading to falls. The facility acknowledged the oversight but did not provide further information on corrective measures. Resident R43 had a fall that was not thoroughly investigated, with missing details on staff interactions and potential causes. The fall investigation lacked information on when the resident was last checked or toileted, and the care plan was not revised to address the fall's root cause. The facility's failure to conduct comprehensive investigations and update care plans contributed to the ongoing risk of falls for these residents.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, potentially affecting 65 of the 66 residents. During a walkthrough of the kitchen, several deficiencies were observed, including food being stored improperly in the freezer with boxes on the floor and food items like hamburger patties and shredded cheese exposed to air. Additionally, milk cartons in the refrigerator were found to be past their expiration date. The kitchen manager acknowledged these issues and took immediate action to discard the expired and improperly stored items. Furthermore, the kitchen had structural issues, such as large openings in the ceiling covered with plastic, which allowed air to blow over the prep tables, and a leaking dishwasher that caused standing water on the floor, making it slippery and difficult to operate. The surveyor also noted that male kitchen staff members with beards were not wearing beard covers, which is a violation of food safety standards. In the storage area, a scoop was found inside a flour bin instead of being hung on the provided hook, and a bowl was found in another flour bin, indicating improper storage practices. Unbaked cookie dough was also found open to the air in the freezer. These observations were shared with the facility's executive director and nursing administration, but no additional information was provided to explain why the facility did not adhere to professional standards for food service safety.
Infection Control Deficiencies in Glucometer and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling and cleaning of shared glucometers and catheter bags. Observations revealed that the shared glucometer on Medication Carts A & D was not cleaned between resident uses. Licensed Practical Nurse (LPN)-P was observed using the glucometer on multiple residents without disinfecting it between uses, contrary to the facility's policy which requires cleaning and disinfecting reusable equipment between uses. LPN-P admitted to only cleaning the glucometer at the start of the day, not between each resident. Similarly, LPN-Q was observed using the same glucometer on multiple residents, cleaning it only with an alcohol wipe for 15 seconds, which does not meet the required disinfection standards. Additionally, the facility failed to maintain proper catheter care for a resident, R48, who had a suprapubic catheter. The resident's catheter bag was observed lying on the floor, which is against the facility's policy that mandates catheter bags be kept off the floor to prevent infections. The resident, who had intact cognition, reported that the catheter bag was left on the floor until they were assisted into a wheelchair before the noon meal, indicating a lack of timely intervention by the staff. These deficiencies highlight lapses in the facility's infection control practices, particularly in the cleaning of shared medical equipment and the handling of catheter bags. The observations and interviews with staff and residents indicate a failure to adhere to established protocols, potentially compromising the safety and comfort of the residents.
Failure to Timely Report Allegations of Abuse and Altercations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft involving three residents within the required timeframe to the State Survey Agency, Nursing Home Administrator, or local law enforcement. In the case of one resident, an allegation of abuse was not reported to the Nursing Home Administrator until two days after the incident, during which time the alleged perpetrator continued to work at the facility. Law enforcement was not contacted regarding this potential abuse allegation, which involved a certified nursing assistant allegedly retaliating against the resident. Another incident involved a physical altercation between family members of a resident in the facility's main dining room. Although local law enforcement was notified and removed one of the individuals involved, the Nursing Home Administrator was not informed until two days later, delaying the report to the State Agency. The Director of Quality Management, who was informed of the incident, did not report it further, believing it unnecessary as no residents were directly involved or harmed. A third resident reported an abuse allegation, claiming to have been held down and changed against their will. This allegation was reported to the Nursing Home Administrator two days after the incident, and subsequently to the State Agency. The delay in reporting was attributed to the belief that the resident frequently complained and that there was no physical evidence of abuse. The facility's failure to adhere to its own policies and regulatory requirements for timely reporting of such incidents was evident in these cases.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation of resident property for three residents. One resident, with a history of Alzheimer's disease and other medical conditions, reported an incident of possible retaliation by a CNA. The CNA continued to work with residents, including the complainant, during the investigation, and law enforcement was not notified. The facility did not provide education to staff regarding the incident, and the investigation was not conducted in accordance with the facility's abuse prevention policy. Another incident involved a resident's family members engaging in a verbal and physical altercation in the dining room. Although law enforcement was contacted, the facility did not interview all staff with knowledge of the incident. The previous NHA did not ensure that staff were educated on abuse prevention and reporting protocols, and the investigation was not comprehensive. A third resident reported being held down and changed against their will, resulting in shoulder pain and a suspected rotator cuff tear. The facility's investigation was incomplete, with only a few staff statements obtained, and not all staff who may have had contact with the resident were interviewed. The previous NHA dismissed the resident's complaint, citing prejudice and a lack of physical evidence, and did not conduct a thorough investigation or provide staff training on abuse reporting.
Failure to Complete Required PASARR Screenings
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for two residents, R4 and R52, who were reviewed for PASARR screening. R4 was initially admitted with a Level I PASARR indicating a stay of less than 30 days, but remained in the facility beyond this period without a revised Level I PASARR or a Level II PASARR being completed. Upon readmission from the community, R4's medical record lacked a new Level I PASARR despite having diagnoses of depression and anxiety and being prescribed psychotropic medications. R52 was admitted with diagnoses of Schizophrenia and Dementia and was receiving psychotropic medications. However, the PASARR Level I screen inaccurately indicated that R52 was not suspected of having a serious mental illness, resulting in the absence of a necessary Level II PASARR. Admission Director-K acknowledged the error in checking the wrong box on the PASARR Level I screen, which led to the oversight. The facility's policy required a Level I PASARR for new admissions and a Level II PASARR if a serious mental illness or developmental disability was suspected. The failure to complete the necessary PASARR screenings for R4 and R52 was attributed to procedural lapses and errors by the admissions staff, as well as a lack of follow-up when the initial 30-day exemption period for R4 expired.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that three residents had individualized comprehensive care plans addressing their specific health needs. Resident 48, who was readmitted with diagnoses including malignant pleural effusion and atrial fibrillation, was on continuous oxygen as documented in their significant change MDS assessment. However, no care plan was initiated for their respiratory or oxygen needs. The Director of Nursing acknowledged that a care plan should have been initiated, but it was overlooked by the Interdisciplinary Team or nursing staff. Resident 55, admitted with multiple diagnoses including chronic pain and major depressive disorder, was observed to have issues with bowel management, as reported by the resident themselves. Despite receiving several medications for bowel issues, there was no care plan in place for bowel monitoring. The Director of Nursing confirmed that a care plan should have been initiated due to the resident's bowel concerns, but it was not done, possibly due to oversight. Resident 57, with diagnoses including chronic kidney disease and congestive heart failure, was documented as frequently incontinent of bladder and bowel. Despite the Urinary Care Area Assessment indicating the need for a care plan to manage incontinence and associated risks, no such plan was initiated. The resident expressed dissatisfaction with the current incontinence care schedule, and staff confirmed that there was no written care plan or care card detailing the required care frequency. The MDS Coordinator suggested that the resident's frequent hospitalizations might have contributed to the lack of a care plan.
Inadequate Monitoring of Bowel Regimen for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R55, received treatment and care in accordance with professional standards of practice. R55, who has a history of chronic pain, abdominal pain, cognitive communication deficit, major depressive disorder, alcoholic cirrhosis of the liver, and a history of infectious and parasitic disease, was experiencing issues with constipation and diarrhea. Despite being on several bowel medications, the facility did not adequately assess or monitor R55's bowel regimen. The facility's policy required resident continence to be assessed on admission, with significant changes, and quarterly, but there was no indication that staff were monitoring R55's bowel movements or the effectiveness of the scheduled and as-needed medications. The surveyor observed that R55 was self-propelling in a wheelchair and expressed ongoing issues with abdominal pain and bowel movements. The medical record review revealed that R55 was on multiple medications for bowel management, but there was no documentation of bowel monitoring or a care plan for bowel management. Additionally, there was a discrepancy between R55's ADL care plan and the CNA worksheet regarding R55's continence status. Interviews with staff, including RN-G, indicated that while staff asked R55 about bowel movements, there was no consistent documentation in the medical record. The surveyor shared these concerns with the executive director and nursing home administrator, highlighting the lack of consistent monitoring and documentation for R55's bowel regimen and abdominal concerns.
Failure to Assess and Manage Incontinence in a Resident
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence was comprehensively assessed and provided with appropriate treatment and services to prevent complications and restore continence. The resident, who was admitted with diagnoses including chronic kidney disease, congestive heart failure, diabetes, morbid obesity, and anemia, was frequently incontinent of bladder and continent of bowel upon admission. Despite being cognitively intact, no comprehensive bowel or bladder assessments were completed, and no care plan was initiated to provide incontinence care on a scheduled basis. Throughout the resident's stay, multiple Minimum Data Set (MDS) assessments documented changes in the resident's continence status, including increased urinary incontinence and eventual bowel incontinence. However, no revisions were made to the resident's Activities of Daily Living (ADL) Care Plan to address these changes. The facility's policy required periodic assessments and the development of a toileting plan, but these were not implemented. The resident experienced a Stage 3 pressure injury, which healed during a hospital stay, but the facility did not revise the incontinence care plan upon the resident's return. Interviews with staff revealed a lack of documentation and communication regarding the resident's incontinence care needs. Certified Nursing Assistants (CNAs) were aware of the resident's incontinence but did not have a written schedule for care. The MDS Coordinator and interim Assistant Director of Nursing (ADON) were unable to provide documentation of a comprehensive incontinence assessment or a care plan. The facility's failure to conduct thorough assessments and implement a care plan contributed to the resident's ongoing incontinence issues and risk for complications.
Failure to Address Significant Weight Changes in Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R40, maintained acceptable parameters of nutritional status, as evidenced by significant weight fluctuations that were not properly identified or addressed. R40, who was admitted with multiple diagnoses including encephalopathy, end-stage renal disease, and type 2 diabetes, experienced notable weight changes over several months. Despite the facility's policy requiring notification of significant weight changes to the dietician and physician, there was no evidence that such notifications occurred for R40's weight loss and gain. The facility's policy on weight monitoring mandates that significant weight changes be identified and discussed in weekly interdisciplinary team meetings, with recommendations from the registered dietician to be implemented by nursing staff. However, R40's medical records showed discrepancies between weights recorded in the electronic health record (EHR) and those documented on dialysis communication forms. These discrepancies were not questioned or addressed by the facility staff, leading to a lack of appropriate nutritional interventions for R40. Interviews with the registered dietician revealed that the dietician was not consistently notified of R40's significant weight changes, and there was a lack of coordination between the facility and the dialysis provider. The facility's executive director acknowledged the belief that the weights entered were incorrect, yet there was no documentation to support that staff questioned these entries. This oversight resulted in the failure to maintain R40's nutritional status within acceptable parameters.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R48, who was reviewed for respiratory care. The deficiency was observed when R48's oxygen tubing and humidification were not labeled and dated, and the humidification water level was below the tubing, preventing effective humidification. Additionally, R48's oxygen was set at 3 liters per minute, contrary to the physician's order of 2 liters per minute as needed to maintain oxygen saturation above 90%. There were no documented orders for the care of oxygen supplies, and the facility's policy on oxygen administration was not followed. The surveyor noted that R48 was readmitted with diagnoses including malignant pleural effusion and atrial fibrillation, requiring total assistance with activities of daily living. Despite the physician's order for oxygen administration, there was no documentation of R48's vital signs or the need for continuous oxygen at 3 liters per minute. The facility's director of nursing acknowledged the oversight, indicating that the third shift should change and label the tubing and humidification, but this was not reflected in the medication/treatment administration records. The surveyor also found no respiratory/oxygen care plan in place for R48, and the assistant director of nursing, executive director, and nursing home administrator were informed of these concerns.
Failure to Provide Adequate Care and Monitoring
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents, leading to significant health declines and, in one case, death. Resident R4 was admitted with multiple health issues, including chronic kidney disease and anemia. The facility did not complete necessary lab work upon admission, failed to monitor R4's edema with daily weights, and did not arrange a follow-up nephrology appointment. These oversights resulted in R4 experiencing a severe health decline, becoming unresponsive, and ultimately passing away after being transferred to the hospital with multiple organ failure. Resident R1, who was admitted with a right femur fracture, dementia, and anxiety, had lab orders related to bilateral lower extremity edema. However, the facility did not monitor R1's edema, and no care plan was implemented to address this condition. Observations noted that R1's legs were not elevated while sitting in a wheelchair, which could have contributed to the edema. Resident R3, diagnosed with hypertension, atrial fibrillation, and diabetes mellitus, was ordered to have three stool samples collected for occult blood testing. Only one sample was obtained, and there was no documentation of a scheduled colonoscopy, which was necessary for further assessment. The lack of follow-through on these medical orders indicates a failure in the facility's processes to ensure residents receive appropriate care and monitoring.
Removal Plan
- Designee will do a facility-wide lab audit to identify any Residents who had lab orders that did not receive the proper follow up.
- Residents identified will have lab order results verified with the provider and appropriate action taken.
- Designee will audit all lab orders to ensure that labs are completed and are completed to the provider.
- Audit results will be reviewed at the QA committee until the QA committee has determined that substantial compliance has been achieved.
- Direct care licensed nurses will be re-educated on the proper procedures for placing lab orders, ensuring that the lab draws occur per provider's orders and that lab results are reported to the providers in a timely manner.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, which are required to assess their skills competency and provide necessary in-service education. This deficiency was identified for five CNAs (CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W) whose records were reviewed. The facility was unable to provide documentation of any performance reviews conducted since their respective dates of hire, which ranged from 2017 to 2023. This lack of performance reviews meant that the facility could not determine areas of weakness or special needs of residents that might require additional training. The Director of Nursing (DON) confirmed the absence of documented performance reviews for the CNAs in question. The facility also lacked a policy and procedure regarding annual performance reviews, which are necessary to ensure the continuing competence of nurse aides. The facility's 2023 training schedule indicated that all annual education, including performance reviews, should be completed by the end of the year. However, the facility did not adhere to this schedule, potentially affecting the quality of care provided to all 72 residents, as staff assignments float throughout the facility.
Deficiency in Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that staff members received the required annual training on Resident Rights, which is crucial for the proper care of residents. This deficiency was identified during a survey where it was found that several staff members, including dietary staff and certified nursing assistants (CNAs), had not received any Resident Rights training since their hire dates. The facility's training schedule included Protecting Resident Rights in Nursing Facilities as a required training, yet there was no documentation to confirm that this training had been completed for the staff members in question. The Director of Nursing (DON) confirmed the lack of documentation for the training and acknowledged the absence of a specific education or training coordinator, implying a gap in the facility's training oversight. Despite the facility's assessment indicating that staff receive education through various means, including new hire orientation and in-services, the surveyor's review of employee records revealed that the required training had not been provided. This oversight had the potential to affect all 72 residents in the facility, as staff were not adequately trained on the rights of residents and the responsibilities of the facility.
Lack of QAPI Training for Facility Staff
Penalty
Summary
The facility failed to ensure that staff received the mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through staff interviews and record reviews, which revealed that several staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and multiple Certified Nursing Assistants, had not received any QAPI training since their hire dates. The facility was unable to provide a policy or procedure regarding QAPI training, and the 2023 MyLearning-Required Annual Training Assignment Schedule did not include QAPI as a required training topic. The Director of Nursing (DON) confirmed the lack of documented QAPI training for the identified staff members and acknowledged the absence of a specific education or training coordinator, indicating that the responsibility fell to the DON. Despite being asked to provide documentation of QAPI training, the facility was unable to produce any evidence that the training had been conducted for the staff in question. This oversight had the potential to affect all 72 residents in the facility, as the staff were not adequately trained in the QAPI program.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that all employed staff received annual training on the written policies and procedures of the facility's Infection Control Program. This deficiency was identified through staff interviews and record reviews, which revealed that several employees, including a Physical Therapist, a Dietary staff member, and multiple Certified Nursing Assistants, did not receive the required Infection Control training since their hire dates. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule indicated that Infection Control and Prevention training should have been completed by all staff by a specified due date, but the facility was unable to provide documentation of such training for the mentioned employees. The Director of Nursing (DON) confirmed the lack of documented Infection Control training for the specified staff members and acknowledged the absence of a specific education/training coordinator, implying that the DON was responsible for this oversight. Despite being asked to provide evidence of training, the DON admitted that no documentation was available. The Nursing Home Administrator and the DON were informed of the concern, but the facility did not provide any additional information regarding why the required training was not conducted.
Lack of Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that staff received the required annual Compliance and Ethics training, which had the potential to affect all 72 residents. The surveyor's investigation revealed that the facility did not have a policy or procedure in place for Compliance and Ethics training. Additionally, the facility's 2023 MyLearning-Required Annual Training Assignment Schedule did not include Compliance and Ethics as a required training topic. The facility assessment, last reviewed and updated on 12/28/23, also did not document Compliance and Ethics training as required. Upon reviewing employee records, the surveyor found no documentation of Compliance and Ethics training for several staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and multiple Certified Nursing Assistants. The Director of Nursing confirmed the lack of documentation and acknowledged the absence of a specific education or training coordinator, indicating that they were responsible for training oversight. Despite being informed of the deficiency, the facility did not provide any additional information or documentation to demonstrate that the required training had been completed.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that staff received the required annual Behavioral Health training, as determined by a facility assessment. This deficiency was identified through staff interviews and record reviews, which revealed that several staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and multiple Certified Nursing Assistants, had not received any Behavioral Health training since their hire dates. The facility was unable to provide a policy or procedure regarding Behavioral Health training, and the 2023 MyLearning-Required Annual Training Assignment Schedule did not include Behavioral Health as a required training topic. The facility's assessment, last reviewed and updated in December 2023, did not document Behavioral Health training as a required component under staff training, education, and competencies. The Director of Nursing confirmed the lack of documented Behavioral Health training for the identified staff members and acknowledged the absence of a specific education or training coordinator. Despite being informed of the concern, the facility did not provide any additional information or documentation to demonstrate that the required training had been completed.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal health information for nine residents. On multiple occasions, surveyors observed report sheets and CNA worksheets containing personal information left unattended on a round table in the dining area of the D unit. These documents included residents' names, physician names, and personal care requirements, such as cognition, behavior, mobility, and dietary instructions. The unattended documents were observed at various times throughout the day, with no staff present in the area to secure them. The surveyor confirmed with the Assistant Director of Nursing that such documents should not be left unattended. Despite being informed of the situation, no explanation was provided as to why the personal information was left exposed. The Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing were made aware of the observations, but the report does not mention any immediate corrective actions taken to address the issue.
Lack of Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all facility and contracted staff, as evidenced by the lack of documentation and formal procedures for required training. The deficiency was identified for eight staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and several Certified Nursing Assistants. The facility's assessment, last updated on December 28, 2023, mentioned that staff receive education through new hire orientation, online learning, and in-services, with additional training provided as needed. However, the assessment did not document that all required trainings were provided. During the survey, the facility was unable to provide a policy and procedure regarding the required trainings, nor could they produce documentation that the staff members had completed the necessary trainings since their hire dates. The Director of Nursing confirmed the absence of a formal training program and acknowledged the lack of a specific education or training coordinator, indicating that they were informally responsible for training oversight. Despite being informed of the deficiency, the facility did not provide additional information or evidence of maintaining records of staff training.
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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