Bayshore Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, Wisconsin.
- Location
- 1300 West Silver Spring Dr, Glendale, Wisconsin 53209
- CMS Provider Number
- 525371
- Inspections on file
- 38
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 68 (5 serious)
Citation history
Health deficiencies cited at Bayshore Nursing & Rehab during CMS and state inspections, most recent first.
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.
A resident with multiple medical conditions who did not eat facility food relied on family-delivered meals and requested staff assistance to heat them. After the unit microwave broke, staff were instructed to use the kitchen, but a dietary aide refused to heat the resident's meal during kitchen clean-up, despite prior approval from the dietary manager. The resident's requests were not consistently accommodated, and limitations were placed on when food could be heated, contrary to facility policy on resident rights and self-determination.
Two residents did not receive adequate supervision or assistance devices to prevent elopement and falls. One resident with cognitive impairment and a history of wandering was found outside after a fall and later went missing overnight, eventually being located by police over a mile away. Both incidents lacked thorough investigation, timely care plan updates, and proper assessment upon return. Another resident fell from bed due to unlocked bed wheels, despite care plan instructions. The facility failed to ensure door alarms were functional and did not consistently monitor or document at-risk residents, resulting in immediate jeopardy.
A CNA verbally abused a resident with moderate cognitive impairment, and the incident was witnessed by a receptionist who failed to immediately report it as required by policy. The CNA continued working the rest of the shift, and the abuse was not reported or investigated until the following day, delaying protective actions for the resident and others.
Two residents' allegations of verbal abuse and misappropriation were not immediately reported to the NHA or Social Worker as required by facility policy. In one case, a resident with moderate cognitive impairment was verbally abused by a CNA, but the incident was only reported the next day after a note was found by the Social Worker. The CNA continued working on the unit until suspension the following day. Another resident's allegation of misappropriation was also not promptly reported, resulting in delayed notification to the State Agency.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
The facility did not employ a certified dietary manager or food service manager, and the current Dietary Director lacked required qualifications and was not enrolled in a certification program. The contracted Registered Dietitian provided only part-time on-site supervision, with the remainder of duties performed remotely. This deficiency affected all residents, as the facility failed to meet regulatory requirements for qualified food and nutrition service leadership.
The facility did not provide evidence that five CNAs completed annual competency reviews or the required 12 hours of in-service training, as outlined in the facility's assessment and federal regulations. Both the DON and NHA confirmed the lack of documentation for these training and competency requirements.
Surveyors found that five CNAs had not received mandatory training in effective communication, as neither the DON nor the administrator could provide evidence of completed training for these staff members.
Five CNAs did not receive required training on resident rights and facility responsibilities, as confirmed by both the DON and NHA when surveyors requested documentation. This deficiency was identified through interviews and record review, potentially affecting all residents.
Five CNAs did not receive mandatory training on abuse prevention, reporting, and dementia care, as confirmed by both the DON and NHA, with no documentation available to verify completion of this education. This lapse potentially impacts all 91 residents in the facility.
Five CNAs did not receive required training on the facility's QAPI program, as confirmed by both the DON and NHA, who were unable to provide documentation of completed training when requested by surveyors.
Five direct care staff members did not receive required infection prevention and control training, and facility leadership could not provide documentation confirming completion of this training when requested by surveyors.
The facility did not provide evidence that five CNAs received required annual compliance and ethics training. When requested, neither the DON nor the NHA could produce documentation confirming completion of this training for the identified staff.
Five CNAs did not receive the required 12 hours of annual training, including dementia care and abuse prevention, as the facility could not provide documentation of completion. Both the DON and NHA confirmed the absence of training records for these staff members, potentially impacting all residents.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents did not receive necessary care and treatment as required by their care plans and physician orders. One resident with a surgical wound did not receive a comprehensive wound assessment within the required timeframe after admission and readmission, with no documentation of refusal on the relevant dates. Another resident, at high risk for skin impairment, did not receive an ordered air mattress, and staff confirmed the order was not followed. The facility also lacked a policy for physician orders.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Staff did not consistently use required PPE, such as gowns and gloves, while providing care to two residents on enhanced barrier precautions for chronic wounds and indwelling devices. Despite clear facility policy and posted signage, some CNAs either omitted gowns or gloves, and one handled a urinary drainage bag without gloves. Staff interviews revealed a lack of understanding of EBP requirements until prompted by signage, and one CNA admitted forgetting to wear a gown during care.
A resident with diabetes, who was cognitively intact, was not informed by staff about a physician's order for an A1C lab test requiring a blood draw. The resident was repeatedly approached by lab personnel for the procedure without prior notice, leading to multiple refusals. There was no documentation in the EMR regarding communication with the resident or her refusals, and the DON confirmed staff did not follow expected procedures for informing the resident or documenting her response.
Surveyors found that two residents receiving tube feedings had persistent dried formula splatter on their IV poles, feeding pumps, and surrounding areas, despite facility policies and staff responsibilities for cleaning. Additionally, a resident's room contained a cracked, unstable sink with sharp edges that had not been repaired or reported, even though it was used daily. These conditions demonstrated a failure to provide a safe, clean, and homelike environment for residents.
A resident's MDS assessment was completed inaccurately, failing to reflect multiple documented refusals of care and evaluation, including blood pressure checks and therapy screening. Despite clear progress notes and staff confirmation of these refusals, the MDS indicated no care rejection, contrary to facility policy requiring accurate attestation by staff.
A resident admitted with multiple complex medical conditions did not have a baseline care plan developed or documented within 48 hours of admission, as required by facility policy. Staff interviews confirmed that neither the resident nor their family received a copy of the baseline care plan, and the DON was unable to locate the required documentation.
A resident was prescribed a new injectable medication and approved to self-administer it and store it at the bedside, but the care plan was not updated to reflect this change. An LPN confirmed the omission after reviewing the care plan, despite facility policy requiring such updates following assessments and medication changes.
A resident with multiple fractures missed a scheduled orthopedic appointment after facility staff provided a transport driver with the wrong provider address. The error occurred because the receptionist failed to confirm the correct city of the medical office, and the facility lacked policies for arranging outside medical appointments and transportation.
A resident with a history of UTIs and an indwelling catheter was observed during incontinence care with the urinary drainage bag improperly positioned in the bed and, at one point, held above the bladder, causing urine to back up. CNAs involved demonstrated insufficient training and awareness regarding correct catheter and drainage bag positioning, contrary to facility policy and the resident's care plan.
Two residents receiving oxygen therapy did not have their oxygen tubing changed or labeled as required by facility policy and physician orders. Observations over several days found the tubing to be sticky and undated, and an LPN confirmed that the equipment had not been properly maintained.
The facility failed to maintain a comfortable and homelike environment due to non-operational heating and drafty windows, resulting in cold temperatures throughout the building. Residents were observed wearing winter clothing indoors and expressed discomfort, with some rooms measuring as low as 57.4 degrees Fahrenheit. Despite a policy to ensure comfortable temperatures, the facility lacked a specific definition of what constitutes comfortable temperatures, and the issue persisted, affecting residents' quality of life.
Two residents were not assessed by the interdisciplinary team for the appropriateness of self-administering medications. One resident with asthma had an inhaler at the bedside without a current assessment, while another resident with multiple diagnoses had various medications and aspirin at the bedside despite not being approved for self-administration. The facility failed to conduct required quarterly assessments, leading to the deficiency.
Two residents received medications late on multiple occasions without their physicians being consulted, as required by facility policy. The medications involved were scheduled for multiple daily doses, and the lack of physician notification was not documented. Interviews with nursing staff revealed inconsistencies in understanding the requirement to notify physicians about late medication administration.
A resident's grievance about missing clothing was not resolved or documented in the facility's grievance logs. Despite reporting the issue to multiple staff members, including a social worker and the former NHA, the grievance was not tracked or fully addressed, leaving the resident without some of the missing items.
The facility failed to administer medications on time for two residents, with numerous instances of late administration beyond the one-hour window allowed by policy. Despite staff interviews revealing inconsistencies in understanding the administration window, the facility's policy requires medications to be given within 60 minutes of the scheduled time. Residents expressed concerns about the timeliness of medication administration, which were acknowledged but not adequately addressed.
The facility had a medication error rate of 10% due to three errors involving incorrect doses of Folic Acid and Vitamin B12, and a missed multivitamin with minerals. These errors were identified through observations and record reviews, involving residents with specific medical needs.
The facility failed to maintain a sanitary environment in its A, B, and C wings, with issues such as stained privacy curtains, dried substances on equipment, and pest presence. The Environmental Services Manager confirmed these issues and acknowledged unclear cleaning responsibilities and recent staffing changes. Interviews revealed ongoing problems with environmental services and a lack of awareness regarding specific cleaning duties.
The facility failed to properly store and dispose of garbage, leading to overflowing dumpsters and trash accumulation. Observations revealed that the dumpsters' lids could not close, and trash was scattered around, attracting flies and gnats. The Administrator and DON confirmed issues with garbage collection due to a payment dispute with the disposal company, which was not the first occurrence of such problems.
The facility failed to maintain an effective pest control program, affecting all residents. Observations revealed gnats and flies in various areas, including resident rooms and administrative offices. The pest control services were limited to the kitchen and exterior perimeter, and the contract did not cover resident units. Staff and residents confirmed the presence of pests, with some residents attempting to swat flies. The Administrator noted that uncollected garbage might contribute to the issue.
A CNA engaged in a verbally abusive exchange with a cognitively intact resident, escalating to a point where the CNA picked up an isolation bin in a threatening manner. The incident was witnessed by staff who intervened, and the CNA was removed from the facility pending investigation.
The governing body of a facility failed to manage its fiscal responsibilities, resulting in over 1.7 million dollars in overdue payments to vendors. This financial mismanagement affected essential services such as waste management, pharmacy, and food distribution, with some vendors suspending services due to non-payment. Despite efforts to arrange payment plans, the lack of timely payments posed a risk to the facility's operations and the well-being of its 101 residents.
The facility did not properly dispose of garbage and refuse, affecting all residents. Surveyors observed pallets and a chemical substance, Pyxis Sour, improperly stored near the dumpster. The facility's policy requires dumpsters to be emptied regularly and garbage not to accumulate outside. The Safety Data Sheet for Pyxis Sour specifies it should be stored in a dry, locked place. The NHA acknowledged the dumpster schedule but did not address the chemical storage issue.
The facility's water management program was found to be incomplete and inconsistent with guidelines, posing a risk of Legionella infection for residents. The program lacked knowledgeable team members, accurate documentation, and effective implementation processes. Additionally, the facility's laundry operations were deficient, with dirty linens stored improperly, leaking washing machines, and inadequate maintenance documentation. The maintenance director was self-taught and not provided with proper training, contributing to these lapses in infection prevention and control.
The facility did not maintain safe operating conditions for mechanical equipment, as observed by a surveyor who found a dryer vent completely covered in lint, posing a fire hazard. Additionally, a 5-gallon bucket of Pyxis Sour and 15 wood pallets were located nearby, increasing the risk. The Maintenance Director confirmed that dryer vents were cleaned monthly, but the observed lint accumulation indicates this schedule was inadequate.
The facility failed to maintain a safe, clean, and homelike environment, affecting two resident units. Observations included unpainted walls, loose handrails, leaking sinks, exposed wires, and dirty windows on the B unit. The C wing had debris, sticky floors, missing tiles, and dust accumulation. Communication issues regarding maintenance and cleaning were noted, with unresolved problems persisting.
A resident with Hemiplegia and Chronic Respiratory Failure was left without a functioning wall fan for two months, causing discomfort due to high temperatures. Despite being cognitively intact and expressing his needs, the facility failed to repair or replace the fan. The DON was unaware of the issue, and the Maintenance Director did not recall any requests for repair. The facility's maintenance records showed no documentation of the issue.
A resident with complex medical conditions had conflicting documentation regarding their code status, with a facility form indicating DNR and a chart stating FULL CODE. Despite attempts to obtain the HCPOA's signature on the State DNR form, it was not secured, leading to a lack of proper documentation for emergency situations.
The facility did not complete the required four-year background checks for three CNAs, potentially affecting all 99 residents. The Business Office Manager, who took over employee files in February, missed these checks during an audit. This oversight was identified during a survey exit meeting with the DON and NHA.
A resident with complex medical needs, including an indwelling catheter and prescribed antidepressant, did not have a comprehensive care plan addressing these issues. The facility's policy requires such plans within 21 days of admission, but this was not done, as acknowledged by the DON.
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 Accommodate Resident Food Preferences and Heating Requests
Penalty
Summary
A deficiency occurred when the facility failed to provide reasonable accommodations for a resident who refused to eat facility-prepared food and relied on meals brought in by family. The resident, who was cognitively intact and had diagnoses including lupus erythematosus, arthritis, protein-calorie malnutrition, and major depressive disorder, stored her food in her room refrigerator and requested that staff heat her meals. The facility was aware of her preferences, as documented in her care plan, but did not consistently meet her requests to have food heated, particularly after the unit microwave broke and staff were instructed to use the kitchen instead. On a specific occasion, the resident requested that a CNA ask a dietary aide to heat up a can of chili. The dietary aide refused, stating she was done cooking and would not do it, despite the resident referencing prior approval from the dietary manager. The dietary aide later acknowledged the refusal, explaining it was during kitchen clean-up and she was already heating food for another resident. The resident reported feeling uncomfortable and hesitant to request warm meals after this incident, and staff interviews confirmed the refusal and the lack of a consistent process for accommodating such requests. The facility's policy on resident rights emphasizes self-determination and the right to make choices about significant aspects of life in the facility. However, the resident's need for her food to be heated was not accommodated in a timely or consistent manner, and limitations were placed on when her food could be heated. The incident was not promptly communicated to the nursing home administrator, who later acknowledged the failure to meet the resident's needs and the unreasonableness of restricting food heating to certain hours.
Failure to Prevent Elopement and Accidents Due to Inadequate Supervision and Device Use
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistance devices to prevent elopements and accidents for two residents reviewed for elopement and falls. One resident with a history of cerebrovascular disease, moyamoya disease, and vascular dementia was found outside the facility in the early morning hours, having fallen and sustained an abrasion. The incident was not thoroughly investigated to determine the root cause of the fall or how the resident eloped from the building. Documentation was unclear regarding the functionality of the door alarms at the time, and there was no evidence that an elopement care plan was initiated following the event. Additionally, the resident's care plan was not updated to address wandering or elopement risks, despite subsequent documentation of wandering behaviors and agitation. A second elopement occurred when the same resident was discovered missing from the facility in the middle of the night and was later found by police over a mile away, sitting at a street intersection. There was no investigation into this elopement, no assessment of the resident upon return, and no revision of the care plan to increase supervision or address the incident. Staff interviews revealed confusion about the resident's risk status, the use and location of elopement binders, and the procedures for monitoring residents at risk for elopement. The facility's documentation did not reflect consistent or timely assessment, monitoring, or communication regarding the resident's behaviors and risks. Additionally, another resident experienced a fall from bed due to the bed wheels not being locked, despite a care plan intervention requiring the wheels to be locked during transfers. Observations confirmed that this intervention was not in place at the time of the fall. The facility's failure to supervise residents adequately, ensure the functionality of safety devices such as door alarms, and conduct thorough investigations into accidents and elopements resulted in a finding of immediate jeopardy. The lack of timely and comprehensive documentation, assessment, and care plan updates contributed to the ongoing deficient practice.
Failure to Immediately Report and Respond to Verbal Abuse by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) was witnessed verbally abusing a resident with moderate cognitive impairment by responding to the resident's greeting with profane and derogatory language. The incident was observed by a receptionist, who did not immediately report the abuse to the Nursing Home Administrator or Social Worker as required by facility policy. Instead, the receptionist wrote a note and placed it under the Social Worker's door, which was not discovered until the following day. As a result, the CNA continued to work the remainder of their shift on the same unit as the resident, potentially exposing the resident and others to further abuse. The facility's policy mandates immediate reporting and investigation of abuse allegations, as well as protective measures for residents. However, the delay in reporting led to a failure to promptly initiate an investigation and to remove the alleged perpetrator from resident care duties. The investigation was not started until the day after the incident, and interviews to rule out further abuse were not conducted with all residents assigned to the CNA on the day of the incident. The resident involved recalled the incident but reported no adverse outcome.
Failure to Immediately Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse and misappropriation involving two residents were immediately reported to the Nursing Home Administrator (NHA) or Social Worker, as required by facility policy. In one instance, a resident with moderate cognitive impairment was verbally abused by a CNA, an incident witnessed by the facility receptionist. Instead of immediately notifying the NHA or Social Worker, the receptionist wrote a note and placed it under the Social Worker’s door, resulting in a delay in reporting. The Social Worker did not become aware of the incident until the following day, and the CNA continued to work on the resident’s unit for the remainder of the shift before being suspended the next day. Additionally, another resident’s allegation of misappropriation of money and property was not reported to the NHA or Social Worker, which also led to a delay in reporting to the State Agency. The facility’s policy requires immediate investigation and reporting of all alleged violations to the Administrator and appropriate authorities within specific timeframes, but these procedures were not followed in these cases. The deficiencies were identified through interviews and record reviews conducted by surveyors.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to manage the food and nutrition services. The Dietary Director (DD) was not certified as a food service manager or dietary manager and was not currently enrolled in a certification program, despite attempts to re-enroll. The DD held a baccalaureate degree in marketing, which does not meet the regulatory requirements for the position. The Registered Dietitian (RD) was contracted to provide oversight but was not on-site full time, working only one to two days per week at the facility and the remainder remotely. The facility did not have a copy of the current contract with the RD readily available, and the contract itself was not fully executed with all required dates. The deficiency affected all 91 residents in the facility, as the DD did not meet the qualifications required to serve as the director of food and nutrition services, and the RD did not provide full-time on-site supervision. The facility had submitted a waiver request to the state agency for the DD's lack of certification, but at the time of the survey, the DD was not actively enrolled in a certification program and had not received responses from the school. The DON and NHA acknowledged these concerns during interviews, and no additional information was provided to demonstrate compliance with staffing or qualification requirements for the food and nutrition service.
Failure to Maintain Required Staff Training and Competency Documentation
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff members, as required by its own Facility Assessment Tool and federal regulations. Specifically, for five Certified Nursing Assistants (CNAs), there was no evidence of completed annual competency reviews or documentation that each had received at least 12 hours of required in-service training annually from their date of hire. The facility's assessment outlined that staff training, education, and competency checks should be provided upon hire, monthly, annually, or as needed based on resident needs and staff performance, covering topics such as resident rights, abuse prevention, dementia care, and HIPAA compliance. During the survey, the Director of Nursing (DON) was unable to provide records of annual competency reviews or proof of the required annual training hours for the five CNAs in question. The Nursing Home Administrator (NHA) also confirmed the absence of this documentation. No additional information or evidence was provided to demonstrate compliance with the training and competency requirements for these staff members.
Lack of Documentation for Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that five direct care staff members received mandatory training in effective communication. During the survey, the surveyor requested evidence from the Director of Nursing (DON) that these staff members, all Certified Nursing Assistants (CNAs) with hire dates ranging from December 2021 to August 2023, had completed the required training. The DON was unable to provide any documentation confirming that the training had been completed for these individuals. The Nursing Home Administrator also confirmed that there was no evidence available to show that the five CNAs had received the mandatory effective communication training. No further information or documentation was provided to the surveyor.
Failure to Provide Required Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that five direct care staff members received training on resident rights and facility responsibilities. During the survey, the surveyor requested evidence from the Director of Nursing (DON) that these staff members, all Certified Nursing Assistants (CNAs) with varying hire dates, had completed the required training. The DON was unable to provide any documentation confirming that the CNAs had received this training. The Nursing Home Administrator (NHA) also confirmed that there was no evidence available to show that the required training had been completed by these staff members. This deficiency was identified through interviews and record reviews, and it has the potential to affect the entire resident census of 91 individuals. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Failure to Provide Required Staff Training on Abuse Prevention and Dementia Care
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) received required training on abuse prevention, reporting procedures, and dementia management. During a survey, the Director of Nursing was unable to provide evidence that these staff members, all of whom had been employed for varying lengths of time, had completed the necessary training. The Nursing Home Administrator also confirmed that there was no documentation available to show that the required education had been provided to these CNAs. This deficiency was identified through interviews and record reviews, and it has the potential to affect the entire resident census of 91 individuals.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that five direct care staff members received mandatory training on the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program. During the survey, the surveyor requested evidence from the Director of Nursing (DON) that these staff members, all Certified Nursing Assistants (CNAs) with varying hire dates, had completed the required QAPI training. The DON was unable to provide any documentation confirming that the training had been conducted for these individuals. This lack of evidence was confirmed in an interview with the Nursing Home Administrator (NHA), who acknowledged that the facility did not have records of the CNAs completing the QAPI training. No further information or documentation was provided to the surveyor.
Failure to Provide Mandatory Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that five direct care staff members received mandatory training on infection prevention and control standards, policies, and procedures as required by the facility's infection prevention and control program. During a survey, the surveyor requested evidence from the Director of Nursing (DON) that these staff members, all Certified Nursing Assistants (CNAs) with varying hire dates, had completed the required training. The DON was unable to provide any documentation confirming that the CNAs had received this training. The Nursing Home Administrator (NHA) also confirmed that there was no evidence available to show that the required infection control training had been completed by these staff members. No additional information was provided.
Lack of Compliance and Ethics Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that five direct care staff members received required training on compliance and ethics. During a survey, the surveyor requested evidence from the Director of Nursing (DON) that these staff members, all Certified Nursing Assistants (CNAs) with varying hire dates, had completed annual compliance and ethics training. The DON was unable to provide any documentation confirming that the training had been completed for these individuals. The Nursing Home Administrator (NHA) also confirmed that there was no evidence available to show that the required training had been provided to the identified CNAs. No further information or documentation was provided to the surveyor regarding this deficiency.
Failure to Provide Required Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) received the required 12 hours of annual training, including education in dementia care and abuse prevention. During a survey, the Director of Nursing (DON) was unable to provide evidence that these CNAs, all of whom had been employed for at least several months, had completed the mandated training. The Nursing Home Administrator (NHA) also confirmed that there was no documentation available to show that the annual training requirement had been met for these staff members. This deficiency has the potential to affect the entire resident census of 91 individuals, as the CNAs are responsible for direct care.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the reporting process, as required by regulations. The report indicates that there was an incident or suspicion of abuse, neglect, or theft, and the facility did not fulfill its obligation to promptly notify the appropriate authorities or provide the outcomes of its internal investigation.
Failure to Complete Timely Wound Assessments and Implement Physician Orders for Pressure Redistribution Mattress
Penalty
Summary
Two residents did not receive necessary care and treatment as required by their care plans and physician orders. One resident was admitted with a surgical wound to the left foot following toe amputation and had diagnoses including chronic osteomyelitis, diabetes, asthma, dementia, and schizophrenia. Upon both initial admission and readmission, a comprehensive wound assessment was not completed until three days after each event, despite no documentation of the resident refusing assessment on those dates. While the care plan and treatment administration record noted the resident sometimes refused dressing changes, there was no documentation of refusals for the specific dates in question, and the director of nursing confirmed that no additional information was available to explain the delay in assessment. Another resident, who was cognitively intact and had diagnoses including systemic lupus, hypertension, morbid obesity, anxiety disorder, and major depressive disorder, had a physician order for a pressure redistribution (air) mattress due to high risk for skin impairment. Despite this order, the resident was observed in a bariatric bed with a regular mattress and reported never having received the ordered air mattress. Staff interviews confirmed the resident should have been on an air mattress per physician order, but there was no documentation or explanation provided for why the order was not followed. The care plan and care card indicated the resident was at risk for skin integrity issues and required regular repositioning, but the specific physician order for the air mattress was not implemented. Additionally, the facility did not have a policy or procedure in place for physician orders when requested by the surveyor. The lack of timely wound assessments and failure to provide ordered equipment, along with missing documentation of resident refusals and absence of relevant policies, contributed to the deficiencies identified during the survey.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Staff Use of PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) while providing care to two residents who were on enhanced barrier precautions (EBP) due to conditions such as chronic wounds, indwelling devices, and enteral feeding tubes. Facility policy required the use of gowns and gloves during high-contact care activities for residents on EBP. In one instance, three CNAs provided incontinence care to a resident with a stage IV sacral ulcer, suprapubic catheter, and gastrostomy tube. Only one CNA wore the required gown and gloves, while another wore only a mask and gloves, and the third wore only a mask. One CNA handled a urinary drainage bag without gloves. The CNAs were initially unable to explain the purpose of EBP but identified the reason after reading posted signage, and two acknowledged not wearing the required PPE. In another case, a resident with a chronic ulcer of the buttocks and an order for wound care was observed receiving a bed bath from a CNA who was not wearing a gown, despite EBP signage and available PPE outside the room. The CNA recognized that the resident was on EBP due to wounds and admitted forgetting to don the appropriate PPE during care. These observations were based on direct observation, record review, staff interviews, and review of facility policy.
Failure to Inform Resident of Lab Draw and Support Self-Determination
Penalty
Summary
The facility failed to inform a cognitively intact resident, who had a diagnosis of type 2 diabetes mellitus, about a physician's order for an A1C laboratory test that required a blood draw. The resident was not notified by staff about the order or the upcoming procedure, and there was no documentation in the electronic medical record (EMR) regarding any discussion with the resident about the lab test or her response. The resident reported being awakened on multiple occasions by laboratory personnel, whom she did not know, attempting to draw her blood without prior notice, leading her to refuse the procedure each time. The resident's roommate confirmed that the resident was upset by these unannounced visits. The Director of Nursing (DON) stated that nursing staff are expected to inform residents of such orders and provide them the opportunity to refuse, as well as document any refusals and notify the physician. However, the DON confirmed that staff failed to document any information regarding the order, the resident's refusal, or any communication with the resident about the blood draw. The laboratory supervisor also confirmed multiple attempts to draw the resident's blood, all of which were refused by the resident. This failure to inform the resident and document the process resulted in the resident not being able to make an informed decision regarding her care.
Failure to Maintain Cleanliness and Safe Environment for Residents
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and safe environment for multiple residents receiving enteral nutrition and for a resident with a damaged sink in her room. Two residents with orders for tube feeding were found to have dried, beige-colored formula splatter on their IV poles, feeding pumps, the floor, and an oxygen concentrator over multiple days. Despite a staff meeting agenda noting that nursing staff were responsible for cleaning up tube feeding spills and housekeeping for mopping, the enteral feeding equipment and surrounding areas remained unclean. The facility's policy required routine cleaning and disinfection of high-touch surfaces, including IV poles, but this was not followed as evidenced by repeated observations of unclean conditions. Additionally, a resident's room was found to have a sink with a large crack and sharp, elevated edges, as well as a broken support brace, making the sink unstable. The resident reported that the sink had been in this condition since she moved into the room and that she used it daily. Both the Maintenance/Housekeeping Director and the Administrator confirmed the hazardous condition of the sink upon observation, but were previously unaware of the issue. Staff members who regularly cleaned or provided care in the room also stated they had not noticed the broken sink. These failures resulted in an environment that was not safe, clean, or homelike, as required by facility policy and resident rights.
Inaccurate MDS Assessment of Care Refusals
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident. Specifically, the MDS assessment for this resident did not accurately reflect multiple documented instances of care and evaluation refusal during the seven-day look-back period. Progress notes in the electronic medical record showed that the resident repeatedly refused blood pressure monitoring and therapy screening, and these refusals were confirmed by both nursing and therapy staff. However, the quarterly MDS assessment indicated that the resident did not reject care or evaluation, which was inconsistent with the documented evidence in the resident's records. Interviews with facility staff, including a Licensed Practical Nurse and the Social Worker responsible for completing the MDS, confirmed that the resident had refused care on several occasions. The Social Worker acknowledged that the MDS was inaccurate after reviewing the progress notes and the assessment. The facility's policy requires staff to attest to the accuracy of the sections they complete in the MDS, but this process was not followed in this instance, resulting in an inaccurate assessment.
Failure to Develop and Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy. Review of the resident's electronic medical record showed no baseline care plan was present under the designated care plan section. The resident was admitted with significant medical conditions, including nontraumatic cerebral hemorrhage with right-sided hemiplegia and hemiparesis, dysphagia, urinary tract infection, and gastrostomy. The facility's policy states that a baseline care plan must be developed within 48 hours of admission and must include the minimum healthcare information necessary to properly care for the resident, as well as a written summary provided to the resident or their representative in an understandable language. Interviews with facility staff and the resident's family confirmed that neither a baseline care plan was created nor was a copy provided to the resident or their representative within the required timeframe. The LPN Unit Manager stated that she had never provided a baseline care plan to residents or families within 48 hours of admission, and the Director of Nursing was unable to locate a copy of the baseline care plan for the resident in question. The family also reported not receiving any documentation outlining the facility's concerns or care areas to be addressed.
Care Plan Not Updated for Self-Administration of New Medication
Penalty
Summary
The facility failed to revise the care plan for one resident following the initiation of a new medication and a self-administration assessment. Specifically, the resident was prescribed Mounjaro, a subcutaneous injectable medication, and was assessed and approved by the interdisciplinary team to self-administer this medication and store it at the bedside. Despite this, a review of the resident's care plan did not show any updates reflecting the new medication or the resident's self-administration status, as required by facility policy. Observations confirmed that the resident kept the Mounjaro syringes in a locked box at the bedside, and an interview with an LPN verified that the care plan had not been revised to include this information. Facility policies require that care plans be updated after each comprehensive and quarterly assessment, and that self-administration determinations be documented in the care plan. The lack of revision meant that staff may not have been aware of the resident's ability to self-administer the medication, potentially leading to confusion.
Resident Misses Medical Appointment Due to Incorrect Transportation Arrangements
Penalty
Summary
A resident with multiple fractures following a motor vehicle accident was admitted to the facility and was cognitively intact, as indicated by a BIMS score of 15. The resident had a scheduled orthopedic appointment to evaluate her right arm. On the day of the appointment, the facility arranged transportation but provided the driver with the incorrect address for the orthopedic provider. As a result, the resident was taken to the wrong location and missed her appointment. The facility's receptionist, who was responsible for arranging the transportation, did not confirm the city of the provider's office and assumed the location, leading to the error. The administrator confirmed that there was no existing policy for transporting residents to outside medical providers or for scheduling medical appointments, and acknowledged that the resident missed her appointment due to the incorrect information provided to the transport driver.
Improper Positioning of Urinary Drainage Bag During Catheter Care
Penalty
Summary
A deficiency occurred when staff failed to properly position a urinary drainage bag for a resident with an indwelling catheter. During incontinence care, the urinary drainage bag was observed in the bed with the resident, and at one point, a CNA held the drainage bag above the resident's waist, causing urine to back up into the bladder area. The resident's care plan directed staff to provide catheter care every shift, secure the catheter and tubing appropriately, and observe for signs and symptoms of urinary tract infection. The facility's policy also required catheter care to reduce bladder and kidney infections. Interviews with the CNAs involved revealed a lack of adequate training and awareness regarding proper catheter and drainage bag positioning. One CNA was unsure of the correct procedure due to limited experience, another did not realize the implications of holding the drainage bag above the bladder, and a third, who was still in training, acknowledged the risk of urine flowing back into the bladder. The resident involved had a history of urinary tract infections and was admitted with an indwelling catheter for urinary retention.
Failure to Maintain and Label Oxygen Equipment for Two Residents
Penalty
Summary
The facility failed to provide proper care and maintenance of oxygen equipment for two residents who required oxygen therapy. For one resident with acute and chronic respiratory failure, asthma, and COPD, observations revealed that the oxygen tubing in use was sticky and lacked a date label on multiple occasions. The facility's policy required weekly changes of oxygen tubing and labeling, but this was not followed, as the tubing remained unchanged and undated over several days. A licensed practical nurse confirmed that the tubing felt as though it had not been changed in quite some time and that night shift nurses were responsible for changing and labeling the tubing. For another resident with acute and chronic respiratory failure, observations also showed that the oxygen tubing was undated over several days, despite physician orders directing staff to change all oxygen tubing, masks, and humidification every Sunday. The lack of labeling and timely changing of oxygen equipment for both residents was directly observed and confirmed through staff interviews and record reviews, indicating a failure to adhere to facility policy and physician orders regarding respiratory care equipment.
Facility Fails to Maintain Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for its residents, as evidenced by the non-operational heating system and drafty windows, which resulted in cold temperatures throughout the facility. During the survey, it was observed that residents were wearing winter coats, hats, and multiple layers of clothing to stay warm. The internal temperatures of the facility's common areas and resident rooms were noted to be cold, with some rooms measuring as low as 57.4 degrees Fahrenheit. Residents expressed discomfort and reported trying to seal drafts in their rooms themselves, indicating that the facility staff did not adequately address the heating issues. The facility's policy on providing a homelike environment includes maintaining comfortable temperatures, but the facility was unable to provide a specific policy defining what constitutes comfortable temperatures. The surveyor's observations revealed that the facility's heating system was not maintaining adequate temperatures, and multiple windows throughout the facility were not sealing properly, creating cold drafts in resident rooms. Despite the facility's implementation of a new guardian angel round form to monitor room temperatures, the surveyor found that the temperatures in many resident rooms were below the baseline comfortable temperature of 71 degrees Fahrenheit. Several residents, including those with cognitive impairments and various medical conditions, were affected by the cold temperatures. For instance, one resident with a history of Type 2 Diabetes Mellitus and Depression was observed with multiple blankets and a scarf, reporting that the room had been cold for two weeks. Another resident with Paraplegia and Chronic Pain Syndrome was wearing a thick pullover and hat, stating that many parts of the building were very cold. The facility's Regional Director of Facilities acknowledged the drafty windows and purchased materials to seal them, but the issue persisted, affecting the residents' quality of life.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, R32 and R1, were assessed by the interdisciplinary team to determine if it was clinically appropriate for them to self-administer medications. R32, who has diagnoses of morbid obesity and asthma, was observed with an albuterol inhaler on the over-bed table. Despite having a BIMS score indicating cognitive intactness, R32's last self-administration assessment was dated over a year ago, and there was no current assessment or documentation supporting her ability to self-administer medications safely. R1, diagnosed with Type 2 Diabetes Mellitus, Venous Insufficiency, Hoarding Disorder, Bipolar, and Depression, was found with multiple medication bottles and aspirin tablets at the bedside. Although R1's BIMS score improved to indicate cognitive intactness, the last self-administration assessment did not approve R1 for self-administration, and no quarterly assessments were conducted thereafter. Additionally, there were no physician orders or care plans authorizing R1 to self-administer medications. The facility's policy requires that residents who wish to self-administer medications must be assessed by the interdisciplinary team to ensure safety, with assessments conducted quarterly or upon significant changes in condition. However, the facility did not adhere to this policy, as evidenced by the lack of current assessments and documentation for both R32 and R1, leading to the deficiency noted by the surveyor.
Failure to Notify Physicians of Late Medication Administration
Penalty
Summary
The facility failed to ensure that the physicians of two residents, R32 and R33, were consulted when medications were administered late over a period from December 30, 2024, to January 22, 2025. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy requires that physicians be notified when medications scheduled for multiple daily doses are administered late, but this was not adhered to in the cases of R32 and R33. R32, who has a medical history including systemic lupus erythematosus, asthma, morbid obesity, chronic pain, depression, hypertension, and anxiety disorder, received multiple medications late on numerous occasions. These medications included Cyclobenzaprine HCI, Buspirone HCI, Propranolol HCI, Gabapentin, and Oxycodone HCI. Despite the repeated delays in medication administration, there was no documentation indicating that R32's physician was consulted about these late administrations. Similarly, R33, who has diagnoses including hyperlipidemia, chronic obstructive pulmonary disease, paranoid schizophrenia, Parkinson's, dementia, and anxiety, also received medications late. The medications involved were Gabapentin and Amantadine HCI, which were scheduled to be administered three times a day. Again, there was no documentation of physician consultation regarding the late administration of these medications. Interviews with nursing staff revealed inconsistencies in understanding the requirement to notify physicians about late medication administration, contributing to the deficiency.
Unresolved Grievance for Missing Clothing
Penalty
Summary
The facility failed to resolve a grievance for a resident, identified as R32, regarding missing clothing. The grievance was initially reported in September 2024, but it was not documented in the facility's grievance logs. R32, who is cognitively intact with a BIMS score of 15, reported the missing clothing to several staff members, including a social worker (SW-T), the former Director of Nursing (DON-B), and the former Nursing Home Administrator (NHA-A). Despite these reports, the grievance was not resolved, and the missing items were not fully replaced. The surveyor's investigation revealed that the grievance was not tracked or documented properly. The Director of Social Services (DSS-N) confirmed that SW-T had filled out a grievance form and submitted it to the grievance officer, who was the former NHA-A. However, the grievance was not listed in the September 2024 grievance log, and there was no clear explanation for this omission. The former NHA-A acknowledged the grievance and mentioned replacing some items, but the grievance process was not completed as required by the facility's policy.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, R32 and R33, as evidenced by the late administration of scheduled medications. R32 did not receive scheduled medications within the required one-hour window before or after the scheduled time on 48 occasions between December 29, 2024, and January 22, 2025. Additionally, on December 15, 2024, R32's day shift medications were not checked and initialed as being administered, leaving the medication administration record (MAR) blank. R32's diagnoses include systemic lupus erythematosus, asthma, morbid obesity, chronic pain, depression, hypertension, and anxiety disorder. R33 also experienced late administration of medications, with 27 instances of medications not being given within the one-hour window between January 2, 2025, and January 22, 2025. R33's diagnoses include hyperlipidemia, chronic obstructive pulmonary disease, paranoid schizophrenia, Parkinson's, dementia, and anxiety. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, yet this was not adhered to for both residents. Interviews with staff, including RNs and LPNs, revealed inconsistencies in understanding the medication administration window, with some staff indicating a one-hour window and others suggesting a two-hour window. The Director of Nursing and Vice President of Clinical Services confirmed the policy of a one-hour window. The Resident Council President and other residents expressed concerns about the timeliness of medication administration, which was acknowledged by the Director of Nursing but not adequately addressed, as evidenced by the continued late administration of medications.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate due to three medication errors out of 30 opportunities. The errors involved three residents: one resident did not receive the correct dose of Folic Acid, another did not receive a multivitamin with minerals, and a third did not receive the correct dose of Vitamin B12. These errors were identified through observations, interviews, and record reviews conducted by the surveyor. The first error occurred when an LPN administered 400 mcg of Folic Acid instead of the prescribed 1 mg to a resident with alcohol dependence. The second error involved an RN who failed to administer a multivitamin with minerals to a resident with severe protein-calorie malnutrition. The third error was identified when an RN administered 100 mcg of Vitamin B12 instead of the prescribed 1000 mcg to a resident. The surveyor confirmed these errors through discussions with the nursing staff and a review of the physician orders.
Sanitation Deficiencies in Facility's A, B, and C Wings
Penalty
Summary
The facility failed to maintain a sanitary environment in three of its four wings, specifically in the A, B, and C wings. During an environmental tour, several issues were identified, including a loose privacy curtain with a large stain in the B Wing, dried substances on an enteral feeding pole, and gnats present in the room. Additionally, the overbed table had dark brown residue, and the room used for resident phone calls and containing an ice machine had sticky residue and trash debris. In the C Wing, a commode seat had dried feces, and the bathroom floor was sticky with gnats present. Privacy curtains were off track, and there were brown stains on the walls and debris on the floor. The Environmental Services Manager (EVM) confirmed these issues during a follow-up tour and acknowledged additional concerns, such as a dirty refrigerator in the C Wing dining room. Interviews with the Director of Nursing (DON) and the EVM revealed that environmental services had been an ongoing problem, with unclear responsibilities for cleaning certain areas and recent staffing changes. The EVM was unaware of specific cleaning responsibilities and acknowledged the presence of pests, but did not connect them to the dried formula spillage.
Improper Garbage Disposal and Storage
Penalty
Summary
The facility failed to ensure proper storage and timely disposal of garbage, as observed in two dumpsters and one enclosed area. The facility's policy on garbage disposal, revised on 03/26/24, mandates that refuse containers and dumpsters should have tightly fitting lids and be kept covered when not being loaded. However, observations on 10/28/24 and 10/29/24 revealed overflowing trash in the dumpsters, with lids unable to close, and trash accumulating on the ground around them. The enclosed area was also halfway filled with trash bags, some of which were partially open, exposing used adult briefs and dressings. Flies and gnats were swarming around all three areas. During an interview, the Administrator and the DON confirmed that garbage disposal was scheduled for Mondays, Wednesdays, and Fridays, but there was no pickup on the previous Friday and Monday. The Administrator stated that the garbage disposal company withheld services due to non-payment, although the corporate office claimed the bill had been paid. Both the Administrator and DON acknowledged that this was not the first time the facility had issues with garbage collection and confirmed that the accumulation of garbage could have contributed to the presence of flies and gnats in the building, as some residents preferred to keep their windows open.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which had the potential to affect all 102 residents. Observations during the survey revealed the presence of gnats and flies in various areas, including resident rooms, common areas, and administrative offices. The facility's pest control policy, revised in April 2024, stated that the facility would maintain a program to eradicate common pests, but the pest control services were only documented for the kitchen and exterior perimeter. Interviews with staff and residents confirmed the presence of pests, and the facility's pest control contract did not cover resident units. Specific incidents included gnats and flies in a conference room, the Director of Nursing's office, and resident rooms. One resident was observed attempting to swat a fly, and another resident complained about the flies. Staff members reported issues with pests, particularly in the secured unit, and noted that the pests were attracted to urine odors. The Administrator acknowledged that garbage had not been picked up for several days, which could contribute to the pest problem. Attempts to contact the pest control company were unsuccessful.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. A Certified Nursing Assistant (CNA) engaged in a verbally abusive exchange with a resident, identified as R4, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The incident occurred when R4, who had a history of becoming easily agitated, yelled at the CNA about job dissatisfaction. The CNA responded by yelling back, which escalated the situation. The CNA then picked up an isolation bin and made a motion as if to throw it at the resident, resulting in further profanities exchanged between the two. The incident was witnessed by a Registered Nurse (RN) and two social workers, who intervened to separate the CNA and the resident. The CNA expressed feeling threatened and justified their actions as self-defense. The facility's policy on abuse/neglect/exploitation was reviewed, and it was noted that the policy aims to protect residents' health, welfare, and rights by preventing abuse. The incident was reported to the state, and the CNA was removed from the facility pending an investigation.
Governing Body's Fiscal Mismanagement Leads to Vendor Payment Delays
Penalty
Summary
The facility's governing body failed to fulfill its responsibilities by not establishing and implementing effective policies and procedures for managing the facility's operations. This deficiency was identified during a survey, which revealed that the facility's fiscal accounts were in arrears, affecting the payment to multiple vendors. The outstanding balances owed to vendors totaled over 1.7 million dollars, with some accounts being overdue for more than 151 days. This financial mismanagement has the potential to impact the facility's ability to provide necessary goods and services for the care and treatment of its 101 residents. The surveyors found that the facility's business office manager and nursing home administrator were not directly involved in handling vendor invoices, as these were managed by the corporate office. Despite assurances from the business office manager that there were no issues with payroll or resident bank accounts, the vendor aging report indicated significant outstanding balances with various service providers. These included essential services such as waste management, pharmacy services, food distribution, and medical supplies, among others. Some vendors had already taken legal action or suspended services due to non-payment. Interviews with facility staff and vendors confirmed the extent of the financial issues. The governing body acknowledged the arrears and stated efforts were being made to arrange payment plans and settlements. However, the lack of timely payments and the potential disruption of services posed a risk to the facility's operations and the well-being of its residents. The governing body's failure to ensure fiscal stability and oversight was a significant deficiency that could affect all residents in the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, which had the potential to affect all 100 residents. During an observation, surveyors noted 15 pallets piled up on the ground near the dumpster and a 5-gallon bucket full of a chemical substance, identified as Pyxis Sour, outside near the dumpster and dryer vent. The facility's Waste Disposal Policy, implemented on 03/01/2020, states that dumpsters should be emptied according to the facility's contract and that garbage should not accumulate or be left outside the dumpster. The Safety Data Sheet for Pyxis Sour indicates that it should be stored in a dry place and locked up. The Nursing Home Administrator acknowledged the dumpster pickup schedule and mentioned arrangements for larger items and pallet removal but did not provide information regarding the Pyxis Sour being outside.
Deficiencies in Water Management and Laundry Operations
Penalty
Summary
The facility's water management program (WMP) was found to be inaccurate, incomplete, and inconsistent with current guidelines, creating a potential risk for all 100 residents to be infected by Legionella or other waterborne bacteria. The WMP lacked knowledgeable team members, an accurate flow diagram, identification of all potential Legionella growth locations, and a process to confirm the program's implementation and effectiveness. The facility's policy and documentation were outdated, with incorrect personnel listed, and there was a lack of training for the current maintenance director, who was self-taught. The surveyor observed several deficiencies in the facility's laundry operations, which could contribute to the spread of infection. Dirty linens were stored in a cart labeled for clean linen only, and there were saturated bath blankets on the floor due to leaking washing machines. The washers were covered in a crusty white substance, and containers with unknown liquids were found without lids. The housekeeping manager acknowledged these issues and stated that they had been reported to the nursing home administrator, but no corrective actions were evident. The facility failed to provide documentation or logs for various maintenance tasks related to water management, such as checking water temperatures and disinfectant levels. The maintenance director admitted to not documenting which rooms or sinks were tested for chlorine levels and stated that there was no formal water management committee. The facility's water management plan was not being followed, and the maintenance director was not provided with adequate training, relying instead on self-teaching. These deficiencies highlight significant lapses in infection prevention and control measures within the facility.
Fire Hazard Due to Inadequate Maintenance of Dryer Vents
Penalty
Summary
The facility failed to maintain mechanical and electrical equipment in safe operating condition, potentially affecting all 100 residents. During an inspection, a surveyor observed a significant fire hazard outside the facility. The dryer vent was completely covered in lint, which is a known fire risk. Additionally, a 5-gallon bucket of Pyxis Sour and 15 wood pallets were located near the dryer vent and dumpster, further exacerbating the fire hazard. The facility's maintenance task log indicated that the dryer vents were cleaned once per month by the Maintenance Director, which was confirmed during an interview with the Maintenance Director. However, the presence of copious amounts of lint on the dryer vent suggests that the maintenance schedule was insufficient to prevent the accumulation of lint, posing a safety risk.
Deficiencies in Facility Cleanliness and Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in two of its units, potentially affecting 53 residents. On the B unit, several issues were observed, including unpainted areas with nails, a loose handrail, missing drywall, and a brown substance on the wall. Additionally, a resident's room had a leaking sink, a hole with exposed wires, and a dirty window with dead bugs. The common area at the end of the hall also had dirty windows and window tracks with dead flies. On the C wing, the surveyor noted debris and dust under furniture, unknown brown matter on curtains, sticky floors, and missing tiles. Crusty brown matter and dried brown splash marks were observed on walls, and a thick layer of dust was found on a ceiling vent. Despite these observations, the maintenance director was unaware of some issues, and the housekeeper mentioned that the auto scrubber was not used due to isolation containment. Communication regarding maintenance and cleaning needs was reportedly done through an electronic system, but some issues remained unresolved.
Failure to Timely Repair Resident's Fan
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as R16, by not repairing or replacing a broken wall fan in a timely manner. R16, who was admitted with diagnoses including Hemiplegia and Chronic Respiratory Failure, was cognitively intact and able to communicate his needs. Despite this, R16's fan was removed approximately two months prior to the survey, and no action was taken to address his discomfort due to the heat in his room. The resident expressed feeling very hot and uncomfortable, which was exacerbated by the high temperature of 86 degrees in the hallway outside his room. The Director of Nurses was unaware of the issue until it was brought to her attention by the surveyor. The Maintenance Director also did not recall any requests for the fan's repair or replacement and noted that the air conditioning in that wing had been out for three days. A review of the facility's maintenance recording system showed no documentation regarding the need for the fan's repair or replacement. These findings were shared with the facility's Administrator and Director of Nurses, but no additional information was provided to explain the lack of timely action.
Failure to Ensure Accurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were accurately documented and available in the medical record. The resident, who was readmitted with multiple complex diagnoses including metabolic encephalopathy, end-stage renal disease, and schizophrenia, had conflicting documentation regarding their code status. A facility DNR/CPR instruction consent form indicated the resident was a DNR, but a green sheet in the resident's hard chart stated FULL CODE. Additionally, the resident's care plan noted the resident as being their own person and a Full Code, while a physician order for Do Not Resuscitate was not initiated until later. The Director of Nursing acknowledged the discrepancy and stated that staff typically refer to the resident's face sheet and physician orders for code status, not the hard chart. Despite multiple attempts to have the resident's Healthcare Power of Attorney (HCPOA) sign the State DNR form, it was not obtained. Progress notes indicated ongoing discussions about the resident's code status, with the HCPOA initially stating the resident was a full code, later agreeing to change to DNR. However, the necessary State DNR form and HCPOA signature were not secured, leading to a lack of proper documentation for emergency situations.
Failure to Complete Required Background Checks
Penalty
Summary
The facility failed to ensure that three out of eight staff members reviewed had the necessary background checks completed every four years, as required by their Abuse/Neglect/Exploitation policy. This oversight had the potential to affect all 99 residents in the facility. Specifically, the background checks for CNAs F, G, and H were not completed by their respective due dates in March 2024. The facility's policy mandates that background, reference, and credentials checks be conducted on potential employees and other associated personnel, with documentation maintained as proof of screening. During the survey, it was revealed that the Business Office Manager (BOM) took over the employee files at the end of February and was in the process of auditing background checks. However, the BOM admitted to missing the background checks for the three CNAs. This lapse was identified during an exit meeting with the Director of Nursing and the Nursing Home Administrator, where the surveyor highlighted the concern regarding the incomplete background checks.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to ensure that an individualized comprehensive care plan was developed and implemented for a resident, identified as R94, who was prescribed an antidepressant medication and admitted with an indwelling catheter. The deficiency was identified during a survey where it was observed that R94 did not have a care plan addressing the use of the antidepressant medication or the management of the indwelling catheter. This oversight was contrary to the facility's policy, which mandates the development of a comprehensive care plan within 21 days of admission, including measurable objectives and timeframes to meet the resident's needs. R94 was admitted with several diagnoses, including osteomyelitis, protein-calorie malnutrition, a stage 4 pressure ulcer, schizophrenia, and urine retention, necessitating the use of an indwelling catheter. Despite these complex medical needs, the facility did not create a care plan to address the catheter's management, even though the resident's Minimum Data Set (MDS) assessment had triggered the need for such a plan. The Director of Nursing (DON) acknowledged the absence of the care plan and indicated it should have been initiated, especially since the resident was admitted with the catheter. Additionally, R94 was prescribed Mirtazapine for depression, but there was no care plan in place to monitor for side effects of this medication. The resident's MDS assessment indicated mild depression, yet the facility failed to document interventions to address this condition. The DON admitted to overlooking the need for a care plan for the antidepressant, despite the facility's policy requiring comprehensive care plans to include resident-specific interventions and monitoring for medication side effects.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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