Careview Health And Rehab Of Minocqua
Inspection history, citations, penalties and survey trends for this long-term care facility in Minocqua, Wisconsin.
- Location
- 9969 Old Hwy 70 Rd, Minocqua, Wisconsin 54548
- CMS Provider Number
- 525678
- Inspections on file
- 40
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 66 (1 serious)
Citation history
Health deficiencies cited at Careview Health And Rehab Of Minocqua during CMS and state inspections, most recent first.
A resident with atrial fibrillation and a history of supratherapeutic INR was discharged from the hospital on warfarin 2.5 mg once daily with specific instructions for repeat INR testing and ACC follow-up. The facility incorrectly transcribed the warfarin order, administering higher doses on two days of the week based on the prior regimen, and failed to enter or carry out any INR monitoring orders or document communication with the ACC. While the resident was also receiving vancomycin and prednisone, which can increase INR, staff did not notify the ACC of these new medications or increase monitoring. Nursing staff later found the resident with significant rectal bleeding, and the resident was hospitalized with a critical INR of 9.3, requiring reversal of anticoagulation.
The facility failed to ensure accurate and continuous administration of critical medications, including antirejection agents, an anticonvulsant, and warfarin. A resident with kidney and pancreatic transplants went without prescribed Mycophenolate Mofetil for over a month and Tacrolimus for several days due to breakdowns in communication and follow-through between facility staff and the pharmacy, leading to significant anxiety, fear, and depression for the resident. Another resident missed several days of ordered Lacosamide for seizure prophylaxis when the drug was repeatedly documented as not available or pending delivery. A third resident did not receive warfarin according to hospital discharge instructions, instead receiving a higher, variable dosing schedule, and a fourth resident received a double dose of warfarin when a previous order was not discontinued. These events were cited as significant medication errors, with one resident experiencing actual psychosocial harm and others placed at risk for more than minimal harm.
Two moderately cognitively impaired residents with multiple comorbidities, including alcohol abuse, COPD, age-related cognitive decline, and cancer, were involved in a dining room incident where one resident loudly yelled at and threatened the other to “shut up,” during which the threatened resident experienced an unwitnessed fall. Staff, including a CNA, an LPN, the SSD, the DON, and the NHA, acknowledged awareness of the yelling and the fall, but there was no documentation in either resident’s record of the altercation, no formal abuse investigation, and no behavior or separation interventions care planned for the resident making threats, despite facility policies requiring prompt reporting, documentation, and investigation of suspected abuse and federal guidance treating resident-to-resident altercations as potential abuse.
Two residents engaged in a verbal altercation in a dining room during which one resident loudly told the other to shut up and threatened to help shut the other up. Staff, including a CNA, the DON, and the SSD, were aware that the residents had been yelling at each other, and one staff member specifically reported hearing the threatening statement. Facility policies require prompt reporting and thorough investigation of suspected abuse, including resident-to-resident incidents, with documentation, interviews, and notification of the Administrator and external agencies as appropriate. However, the NHA acknowledged that no formal investigation or documentation was completed for this incident, and review of both residents’ records showed no notes or care plan interventions related to the altercation or to protecting either resident from further verbal abuse.
A resident with multiple comorbidities and intact cognition, care planned for substantial/maximal ADL assistance and at risk for falls, was documented by PT as requiring a two-person Hoyer lift for all transfers, with a PT communication sheet confirming dependence on a mechanical lift. Despite this, staff continued to use a sit-to-stand lift and later a two-person stand-pivot transfer, contrary to PT’s determination that the resident was not appropriate for sit-to-stand and could not safely bear weight. The resident reported fear of these transfers and often refused to get out of bed. The care plan and CNA guidance listed only “weight bearing assistance” rather than Hoyer use, and interviews with CNA, ADON, PT, PTA, and DON showed that therapy staff consistently considered the resident a Hoyer-only transfer while nursing leadership acknowledged that PT-recommended transfer changes were not promptly reflected in the care plan or CNA task lists, and that the resident was not identified in the facility’s transfer audit.
A resident with CHF, acute kidney failure, dysphagia, hemiplegia, and underweight BMI, receiving tube feeding, was admitted with orders for daily morning weights that were not consistently implemented, resulting in undocumented gaps and an 11-lb (9.55%) loss early in the stay, followed by further significant weight loss. The care plan identified high nutritional risk and later added daily weights after a 10% weight loss in 30 days, yet some ordered daily weights were still not documented and no refusals were recorded. The facility’s enteral nutrition policy required an RD assessment at admission for residents on tube feedings or consultation with an on-call RD before the first feeding, but the RD did not assess the resident until a week after significant weight loss was identified, and only one RD note was found. The DON acknowledged that daily weights were not started on admission despite the physician’s order and that the RD became involved only after weight loss, contrary to facility policy.
A resident with complex medical conditions and a PICC line for chronic IV daptomycin therapy did not consistently receive ordered IV care and PICC maintenance. Physician orders and the care plan required q8h normal saline flushes, regular PICC dressing changes, arm circumference and external catheter length measurements, PICC site monitoring, needless connector changes, and scheduled IV daptomycin doses after dialysis. MAR review showed frequent missed or undocumented flushes, missed measurements and connector changes on specified days, and multiple missed IV daptomycin doses, while a photo showed a PICC dressing still dated from mid-month despite MAR entries indicating later dressing changes. Hospital records later noted the PICC had been accidentally removed at the facility within the prior 24 hours, and EMT documentation did not show a PICC in place. In interviews, an LPN denied performing PICC care despite their initials on the MAR, an RN was uncertain whether the PICC was present at transfer, and the DON was unaware of the missed care and documentation discrepancies, confirming staff were expected to follow all provider orders.
A resident with ESRD, a left forearm fistula, and multiple comorbidities did not receive dialysis-related monitoring and assessments as ordered and care-planned. Facility policy and physician orders required thrice-weekly dialysis with pre/post weights, M/W/F vital signs, and regular assessment of the fistula for thrill, bruit, and site concerns, with abnormal findings reported to the provider. Record review showed no documented fistula assessments, inconsistent and infrequent weights instead of ordered pre/post dialysis weights, and missing M/W/F vitals. Episodes of significantly elevated BP were not accompanied by documentation of provider notification or interventions. Staff interviews revealed confusion about responsibilities for fistula assessment, and the DON acknowledged that staff were not accurately monitoring the resident’s pre- and post-dialysis care.
A resident with chronic pain and an order for Voltaren 1% gel with specific gram limits per application and per day received the medication without proper dose measurement. A CMA squirted gel into a medication cup without using the manufacturer’s dosing card, applied some to the resident’s knee and the rest to the resident’s back, and reported not knowing how many grams were being administered, relying instead on informal teaching to apply a thin layer. The DON stated that topical medications were generally applied as a thin layer, was unsure how correct doses were ensured for topicals, and was unaware of the Voltaren dosing card and carton dosing instructions, contributing to a medication error rate above 5%.
The facility failed to ensure resident dignity and self‑determination when a video camera with audio capability, installed by a resident’s POA in a shared room, remained in use without documented consent from either resident or their representatives. A cognitively impaired resident and that resident’s guardian were not properly informed of the camera’s presence, and the guardian later reported being unaware and uncomfortable with it. Record review showed no signed consent for the camera from the roommate’s POA and no documentation of any discussion at a care conference, and neither resident’s care plan addressed the ongoing audio/visual surveillance in the room.
A resident admitted with confusion, a history of falls, and moderately impaired cognition was care planned as a fall risk with limited initial interventions, but the care plan was not updated after multiple subsequent falls, including one with major injury. Although new fall interventions (such as a "Call for Help" sign and changes in mobility equipment placement) were documented in other records and observed in the room, they were not incorporated into the formal care plan. Staff described different fall interventions based on report and observation rather than a unified, updated care plan, and the DON confirmed that nursing staff had not revised the care plan to include the post-fall interventions.
A resident with multiple comorbidities and identified risk for pressure ulcers developed a left heel pressure injury that was not comprehensively assessed by nursing staff, was initially misdocumented as being on the right heel, and did not trigger timely updates to the care plan. When the wound care MD ordered more intensive treatment, including Betadine and twice-daily dressing changes, nursing staff failed to transcribe and implement these orders, continuing a less frequent regimen. Comprehensive wound assessments between weekly MD visits were not performed, and facility leadership acknowledged that nurses relied on limited SBAR documentation instead of full assessments. The heel wound progressed to a Stage 4 PI with osteomyelitis and sepsis, and hospital records confirmed a diagnosis of left calcaneal osteomyelitis and Stage 4 heel PI, supporting the finding that the facility did not provide pressure ulcer prevention and treatment consistent with professional standards.
Surveyors found that the facility did not ensure an RN was on duty for at least eight consecutive hours on multiple days, based on PBJ staffing data and review of staff schedules and nurse postings. Interviews with administration revealed that daily staffing postings were created by a receptionist and not manually updated to reflect changes, and that internal schedules, which were not publicly posted, were relied upon instead. Although documentation was later provided to show RN coverage on one of the questioned days and administration reported that corporate RNs rotated to provide coverage, the facility could not produce records confirming eight hours of RN coverage on three specific days, affecting all residents.
Surveyors found that the facility failed to provide required bed-hold and transfer/discharge notices to multiple residents during hospital transfers. Cognitively intact and moderately impaired residents were transferred for changes in condition and hip pain without receiving written notice of the bed-hold policy, reserve payment terms, or specific reasons for transfer/discharge. In some cases, bed-hold forms were signed by managed care organization staff but lacked required details such as the daily reservation rate, and one resident did not receive a new bed-hold notice for a later hospital transfer. During the survey, the social worker responsible for these processes was unavailable, and leadership staff could not clearly describe the transfer/discharge notification process.
A resident’s family reported multiple missing personal items, including a cell phone, wallet with cash, shoes, grabbers, and a box containing keys. The facility’s policies required prompt reporting of misappropriation to appropriate agencies and a thorough investigation with interviews of the resident, reporter, witnesses, and involved staff. However, the facility did not report the allegation to the State Agency, delayed starting its investigation, and ultimately produced only a single grievance form documenting limited room and laundry searches and no detailed investigative steps, while the missing property was never located.
The facility failed to conduct timely and thorough investigations into two separate allegations involving residents. In one case, a resident’s family reported missing personal items, including cash, but the facility delayed starting the investigation, documented only a room and laundry search, did not interview staff or other residents, and was unable to locate the property. In the other case, a resident with moderate cognitive impairment and a history of falls developed significant pelvic fractures of unknown origin; the facility’s investigation consisted of limited staff interviews, no direct interview with the resident, no complete physical/emotional assessment, incomplete documentation, and no clear determination of how or why the injury occurred. These actions did not follow the facility’s abuse prevention and investigation policies, which require prompt, comprehensive investigations and interviews of all relevant parties.
Two residents did not receive care according to physician orders and professional standards. One resident with bilateral lower extremity wounds and toe amputations had active TAR orders for nightly dressing changes, infection monitoring, and documentation of drainage and pain, but there was no TAR documentation of dressing changes or wound assessments over multiple consecutive days, the care plan did not address wound care, and the resident reported dressings had not been changed since admission. Another resident with hypertension and chronic kidney disease fell from a recliner and was found with low BP; the NP ordered hourly BP monitoring and holding of BP medications until BP normalized, but there was no documentation of ongoing BP checks or that medications were held as ordered, beyond MAR entries, and the DON could not locate evidence that these monitoring orders were followed.
Two residents did not receive required safety interventions to prevent accidents. One resident with dementia and severe cognitive impairment, assessed as an elopement risk and care planned for a wanderguard on the left wrist with shift checks documented on the TAR, was repeatedly observed without a wanderguard on any limb or wheelchair, while staff documentation and interviews showed uncertainty and inconsistency about the device’s presence. Another resident with moderately impaired cognition and a care plan requiring a two‑person transfer with a gait belt was observed being transferred from the toilet to a wheelchair by a single CNA without a gait belt, and the CNA reported not using a gait belt for that resident’s transfers and believing the care plan did not require it.
The facility did not ensure that daily nurse staffing postings accurately reflected the total and actual hours worked by licensed and unlicensed nursing staff per shift, potentially affecting all 47 residents. A posted Direct Care Report in the lobby was outdated, and review of schedules and postings over several weeks showed that staffing changes recorded on internal schedules were not consistently updated on the public staff postings. The NHA and assistant NHA reported that the receptionist posts staffing information once in the morning after updating the census, and that subsequent staffing changes are not manually updated on the posted report.
A resident admitted after hospitalization for severe groin infection did not receive prescribed wound VAC therapy or vancomycin solution as ordered in hospital discharge instructions. Facility staff were unaware of the specific wound care needs, did not consult a physician when supplies were unavailable, and failed to document or provide ordered treatments. The wound VAC was delayed, and the wound became contaminated with stool, leading to the resident being sent to the emergency room for care.
A resident admitted after hospitalization for severe groin infection and wound debridement did not have a baseline care plan developed for wound care within 48 hours, despite physician orders for wound VAC and vancomycin irrigation. The care plan only addressed the Foley catheter and advanced directives, and an LPN confirmed the omission of wound care planning.
A resident with a severe groin wound requiring a wound VAC and vancomycin irrigation did not receive care as ordered. Facility staff failed to implement a baseline care plan for the wound, did not order or apply the wound VAC in a timely manner, and did not administer the prescribed vancomycin solution. The wound was left exposed, became contaminated with stool, and the resident experienced significant pain, ultimately requiring transfer back to the hospital.
The facility did not have an RN serving as DON as required, instead appointing an LPN to the role and leaving the position vacant for a period. During this time, multiple complaint investigations resulted in citations for issues such as pharmacy services, catheter care, and medication errors, and the facility experienced a high number of grievances.
The facility did not timely or adequately request a waiver when unable to recruit a registered nurse for the DON position. After the previous DON resigned, the facility was without an RN in this role and failed to provide the State Agency with requested evidence of recruitment efforts or assurances for resident safety. The acting DON did not meet RN requirements.
The facility's call light system was not fully operational, with auditory alarms and nurse's station alerts nonfunctional for several weeks. Multiple residents and family members reported excessive wait times for assistance, and some residents had to leave their rooms to seek help. Staff confirmed the system's deficiencies, and maintenance efforts to repair the outdated system were unsuccessful, as documented by invoices and grievance records.
Licensed staff did not immediately initiate CPR for a resident with a full code status who was found unresponsive and not breathing. The CNA who discovered the resident left the room to find a nurse rather than calling for help or starting CPR, and the LPN who responded also did not begin CPR, instead instructing the CNA to get the RN. CPR was only started after the RN arrived and the resident was repositioned, resulting in a delay that was not in accordance with facility policy or the resident's documented code status.
A resident with a PICC line for IV antibiotics did not have documented orders or records for routine line care, including flushing, dressing changes, or site monitoring. Staff confirmed the lack of standing orders, and the omission led to a line occlusion requiring hospital intervention.
Two residents did not receive their scheduled medications at the prescribed times, with doses of clonazepam, baclofen, buspirone, and gabapentin administered either hours late or too close together. Staff interviews revealed inconsistent understanding of medication timing policies, and facility records showed that required administration windows were not followed.
A resident with a diagnosis of gram-positive bacteremia did not receive two scheduled doses of IV Vancomycin because the medication was not available in the facility. Despite pharmacy communication and refaxing of orders, the first dose was not administered until two days after the prescribed start date, and the nurse practitioner was not informed of the missed doses. Facility policy required timely administration of medications, which was not followed in this case.
A resident with multiple medical conditions and moderate cognitive impairment was found unresponsive in a position suggesting a possible injury of unknown origin and required CPR. Staff did not complete an incident report, and the QAA committee did not identify, investigate, or review the adverse event, despite facility policy requiring such actions for negative outcomes and adverse events.
Three residents with indwelling catheters did not receive care consistent with professional standards, as staff failed to consistently monitor, document, and report urinary output per physician orders and facility policy. In one case, a resident with a suprapubic catheter experienced two days of increased incontinence and lack of catheter drainage, leading to hospitalization for a severe UTI, with no evidence of timely assessment or provider notification. Similar documentation and assessment failures were found for two other residents.
The facility did not provide required Bedhold and transfer notices, nor did it notify the Ombudsman, when a resident with a Power of Attorney, a resident with a legal guardian, and a resident with multiple sclerosis and neurogenic bladder were transferred to the hospital following changes in condition. The Nursing Home Administrator confirmed these notifications were not given.
Surveyors observed that drugs and biologicals, including lorazepam and eye drops, were stored in unlocked refrigerators and lacked proper labeling. Expired intermittent catheters were also found in the medication storage room. Staff, including a CMA and an LPN, were unable to demonstrate knowledge of expiration dates or proper storage procedures, and the DON confirmed the presence of expired and improperly stored items.
The facility did not consistently monitor or record internal food temperatures during meal service, resulting in a resident being served over-easy eggs at 107.2°F, below the required 135°F. Staff did not check the temperature of the eggs before serving, and food logs only documented temperatures at the start and end of service, not during tray delivery.
Two residents did not receive medications as ordered due to transcription errors and missed doses, with one resident receiving an incorrect Aspirin dose for several weeks and another missing evening medications on two occasions without proper documentation in the eMAR.
A resident with a history of urinary tract infections and chronic catheter use had a urinalysis ordered by a urologist, which revealed significant bacterial growth. The facility did not notify the ordering urologist or the primary provider of these results, as the order was incorrectly placed under the medical director. Four days later, the resident was hospitalized for sepsis, and staff interviews confirmed that the providers were not made aware of the lab findings.
The facility did not update its facility-wide assessment to reflect a significant increase in resident census, resulting in insufficient staffing levels. Staff interviews revealed that CNAs and RNs struggled to manage the increased workload, leading to delays in resident care and staff resignations. The Nursing Home Administrator acknowledged the outdated assessment and staffing ratios, which were based on previous census figures.
Two residents in the facility did not receive appropriate care according to their care plans and professional standards. One resident with CHF did not have necessary assessments or lab tests completed, leading to hospitalization for CHF exacerbation and myocardial infarction. Another resident with multiple wounds did not receive timely skin assessments or wound care, resulting in hospitalization and amputation. Staff interviews revealed lapses in monitoring and documentation, contributing to the residents' deteriorating conditions.
The facility failed to ensure proper food handling and sanitization practices, risking foodborne illnesses for all 28 residents. Observations showed improper glove use, lack of hand hygiene, and inadequate hair restraints by staff. Additionally, food items in the kitchen were not labeled or dated, violating facility policies. Interviews confirmed expectations for labeling and monitoring food items, but these were not consistently followed.
A resident with a history of heart conditions experienced difficulty breathing and was transferred to the ED without immediate notification to their physician. The facility failed to document or inform the physician of the resident's condition and transfer, which was only communicated the following day, contrary to standard practice expectations.
A resident with schizoaffective disorder and prescribed psychotropic medications did not receive a required PASRR Level II screening. Although a Level I screening indicated the need for further evaluation, and form F-20822 was completed recommending short-term exemption, no specific exemption was chosen, and the necessary Level II screening was not conducted. The Nursing Home Administrator confirmed the oversight.
A resident at risk for pressure injuries did not receive adequate care as the facility failed to apply prescribed heel protector boots consistently and did not conduct thorough skin assessments. The resident was admitted with multiple pressure injuries, but the facility did not document their locations, sizes, or stages, leading to unclear progression of the injuries. Staff interviews revealed inconsistencies in applying the boots and documenting their application.
A facility failed to implement a resident's ambulation program, as outlined in their care plan, to maintain mobility and minimize fall risk. Despite the resident's medical conditions, staff did not offer ambulation opportunities, and the facility lacked a maintenance or restorative program. Observations showed the resident was transported in a wheelchair without being offered to walk, and no evidence of the walking program was found in the resident's records.
A facility failed to assess a resident with an indwelling catheter for its removal, contrary to their policy. The resident, admitted with conditions like benign prostatic hyperplasia and UTI, was not evaluated for urinary continence or a toileting program. The DON admitted that routine catheter changes did not align with standards, and the facility lacked documentation to justify the catheter's continued use.
The facility failed to maintain proper infection control practices for two residents. One resident with an indwelling catheter was under Enhanced Barrier Precautions, but a CNA did not wear a gown as required. Another resident tested positive for COVID-19, but there was no droplet precaution signage on the door, leading to staff potentially entering without proper PPE. The Director of Nursing and an RN confirmed these lapses in protocol.
Failure to Accurately Transcribe and Monitor Warfarin Therapy Resulting in Critical INR and GI Bleeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs and appropriately monitored, specifically related to warfarin therapy. The resident had chronic atrial fibrillation and was discharged from the hospital on warfarin 2.5 mg orally once daily with explicit instructions for repeat INR testing and follow-up with an anticoagulation clinic (ACC). At discharge, the resident’s INR had been supratherapeutic at 5.6, warfarin was held, and then the INR decreased to 3.2 prior to discharge, with recommendations for repeat INR testing on specified dates. The facility did not correctly transcribe the hospital’s warfarin order; instead, staff entered an order for 2.5 mg (two tablets) on Mondays and Fridays and 2.5 mg (one tablet) on the remaining days, effectively giving extra warfarin doses on Mondays and Fridays based on the resident’s previous regimen rather than the new discharge instructions. The facility also failed to implement and carry out INR monitoring orders and communication with the ACC as indicated in the hospital discharge summary and as described by facility practitioners. Although the discharge summary directed ongoing INR monitoring and follow-up with the ACC, no INR orders were transcribed into the resident’s record, and no INR tests were obtained during the resident’s stay. Progress notes from the NP and PA referenced that nursing should contact the ACC for warfarin dosing and INR monitoring, and the NP documented being assured by the DON that nursing had reached out to the ACC. However, there was no documentation of ACC orders, INR results, or any INR/warfarin log entries for this resident during the relevant period. An order for PT/INR every Monday and Thursday was later entered with a start date backdated to the admission date, but this was created after the resident had already been transferred to the hospital. During this time, the resident was also receiving medications known to interact with warfarin and potentially increase INR, including vancomycin for C. difficile infection and prednisone for cough. There was no documentation that staff notified the ACC of the initiation of prednisone or that monitoring was increased in response to these additional medications. Nursing staff reported that they did not obtain any INRs for the resident and that there were no active INR orders in the electronic record while the resident was present. Ultimately, an RN found the resident with a large amount of blood in the stool and on an incontinent pad, with additional blood expelled from the rectum when the resident was repositioned and transferred to a stretcher. The resident was sent to the emergency room and was found to have a critical INR of 9.3, requiring administration of vitamin K and Kcentra to reverse the anticoagulation and prevent further bleeding.
Failure to Ensure Accurate and Continuous Administration of Critical Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, particularly related to critical medications such as antirejection agents, anticonvulsants, and anticoagulants. One resident with a history of kidney and pancreatic transplants (R5) did not receive prescribed antirejection medications Mycophenolate Mofetil and Tacrolimus for extended periods. The MAR showed Mycophenolate Mofetil was not given or held for 37 days, and Tacrolimus was not given or held for several days. Progress notes documented that Mycophenolate Mofetil was not in the facility, required prior authorization, and was on hold per the nurse practitioner, with repeated entries that it was ordered but not available. For Tacrolimus, notes indicated it was ordered, held per the nurse practitioner, or ordered but not yet delivered. There was no medication error report found for the missed Tacrolimus doses. The pharmacy’s business assistant reported that the facility first requested refills for R5’s antirejection medications on a specific date and that the pharmacy repeatedly sent forms requesting transplant-related information and clarification on payment responsibility. The pharmacy documented multiple attempts over several days to obtain the needed information from the facility, with no response, leading the pharmacy to place the medication request on hold (“profiled”) until the facility reinitiated contact about a month later. The medications were eventually dispensed only after the DON agreed the facility would cover the cost pending insurance information. Interviews with the pharmacist and pharmacy staff emphasized that the facility commonly failed to respond in a timely manner to pharmacy requests. The DON later stated that staff should have notified the provider immediately about the interruption of antirejection medications, acknowledged awareness of the resident’s concern about not receiving these medications, and initially attributed the problem to the pharmacy not sending medications. The DON could not produce documentation showing that the requested pharmacy form had been completed prior to late March. R5 and a family member reported that the resident repeatedly asked the facility to refill antirejection medications and became anxious, afraid, and depressed when the medications were not provided for over a month. R5 stated that the transplant physician had instructed that antirejection medications were lifelong and should not be missed, and described daily feelings of anxiety, fear, and depression due to the prolonged lack of medication. The family member reported not being contacted for weeks and observed that the resident had become increasingly anxious, depressed, withdrawn, and preferred to stay in the room, feeling like a nuisance to staff. Facility staff, including the ADON, acknowledged that the resident and spouse were upset and concerned about transplant rejection and that the lack of antirejection medications could be contributing to the resident’s seclusion. Another resident (R3) with a history including end-stage renal disease, kidney transplant, and seizure prophylaxis was ordered Lacosamide 100 mg twice daily as an anticonvulsant. The MAR showed that Lacosamide was not given or held for four consecutive days. Progress notes documented that the medication was not available, ordered but not received, pending delivery, and that pharmacy had been called for a refill with an e-script request sent to the provider. The DON stated not knowing the resident was on an anticonvulsant and agreed the seizure medication should not have been missed, while also stating a belief that the missed doses did not contribute to the resident’s subsequent hospitalization. The nurse practitioner reported being unaware that the anticonvulsant had been missed for four days and stated that anticonvulsant medications should not be stopped abruptly. A third resident (R2) with chronic atrial fibrillation and other cardiac conditions was discharged from the hospital with instructions to take warfarin 2.5 mg orally once daily and to have repeat INR monitoring. The hospital discharge summary noted that the resident’s INR had been supratherapeutic on admission, warfarin had been held, and the INR had decreased prior to discharge, with specific follow-up INR dates recommended. At the facility, however, the medication orders documented that the resident was to receive warfarin 5 mg (two 2.5 mg tablets) on Mondays and Fridays and 2.5 mg on the remaining days, which did not match the hospital discharge instructions for a consistent 2.5 mg daily dose. A fourth resident (R9) experienced a warfarin dosing error when the facility failed to discontinue a previous warfarin order, resulting in the resident receiving a double dose. The report notes that R5’s case was cited at severity level 3 (actual harm) due to psychosocial harm manifested by ongoing anxiety, fear, and depression related to the prolonged lack of antirejection medications. The other residents’ cases (R2, R3, and R9) were cited at severity level 2 for potential for more than minimal harm. Across these examples, the facility did not follow its own medication ordering and receipt policy, did not ensure timely communication and follow-through with the pharmacy, did not consistently notify the provider of prolonged medication unavailability, and did not adhere to hospital discharge orders for warfarin dosing, resulting in significant medication errors and missed critical therapies.
Failure to Protect Resident From Verbal Abuse and Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by another resident and to investigate and document a resident-to-resident altercation associated with a fall. Facility policy states that residents have the right to be free from abuse, including verbal abuse, and that suspected abuse incidents must be documented and reported to the Administrator within specified time frames, with an immediate investigation and written findings. The policy copy provided to the surveyor contained blanks where required reporting time frames should have been specified. The State Operations Manual Appendix PP requires facilities to treat resident-to-resident altercations as potential abuse, investigate all incidents, assess residents for injuries, develop care plans to prevent recurrence, and report incidents. One resident (R11), admitted with diagnoses including alcohol abuse with intoxication, atrial fibrillation, COPD, and sepsis, had an MDS showing clear speech, moderate cognitive impairment (BIMS 12/15), and no documented behaviors. R11’s care plan, initiated in February and last revised in March, contained no behavior or resident-to-resident altercation interventions. Another resident (R12), admitted with age-related cognitive decline, bladder cancer, type 2 diabetes, prosthetic heart valve, and chronic kidney disease, had an MDS showing clear speech, moderate cognitive impairment (BIMS 8/15), and no documented behaviors, but the care plan identified potential for physical aggression related to poor impulse control and directed staff to analyze triggers and intervene early when the resident became agitated. On the date of the incident, staff reported that R11 was heard yelling at R12 in the dining room, telling him to “shut up” and threatening that if he did not shut up, R11 would help him shut up. During this time, R12 experienced a fall in the dining room that was not witnessed. Multiple staff interviews confirmed awareness of the yelling and altercation but revealed a lack of documentation and formal investigation. A CNA reported hearing R11 yell threatening statements at R12 and stated that R12 fell while R11 was yelling, but there was no documentation in either resident’s medical record about the altercation. The LPN on duty stated that everyone heard the residents yelling, that she was told about the fall, and that staff discussed hearing them yell at each other, but she did not recall the exact words and was unaware of any care-planned interventions to monitor or separate the residents. The Social Services Director acknowledged hearing about the incident, stated that R12 can be loud and repetitive and that R11 gets irritated and yells at him to shut up, and confirmed that the fall was documented on the same date as the yelling. The DON recalled being aware that the residents were yelling and that R12 fell that day, but there was no contemporaneous investigation of the verbal altercation as potential abuse. The Administrator stated that he only completes written investigations if an incident is reportable, did not conduct a formal investigation of the yelling incident, had no documentation of what was said, and acknowledged that staff heard the altercation in the dining room. Review of the fall report showed no mention of the yelling or altercation, and there was no evidence of an abuse investigation or care plan revisions related to the resident-to-resident verbal abuse. Title: Failure to Protect Resident From Verbal Abuse and Investigate Resident-to-Resident Altercation ShortSummary: Two moderately cognitively impaired residents with multiple comorbidities, including alcohol abuse, COPD, age-related cognitive decline, and cancer, were involved in a dining room incident where one resident loudly yelled at and threatened the other to “shut up,” during which the threatened resident experienced an unwitnessed fall. Staff, including a CNA, an LPN, the SSD, the DON, and the NHA, acknowledged awareness of the yelling and the fall, but there was no documentation in either resident’s record of the altercation, no formal abuse investigation, and no behavior or separation interventions care planned for the resident making threats, despite facility policies requiring prompt reporting, documentation, and investigation of suspected abuse and federal guidance treating resident-to-resident altercations as potential abuse.
Failure to Investigate Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse between two residents and to implement protective interventions. On 3/29/26, staff became aware of an altercation in the dining room in which one resident (R11) yelled at another resident (R12), telling R12 to shut up and stating that if R12 did not shut up, R11 would help shut R12 up. A CNA reported hearing this exchange, and the DON recalled being informed that the residents were yelling at each other in the dining room, although she was unsure of the exact date. The facility’s own policies define verbal abuse as the use of oral, written, or gestured language that includes disparaging or derogatory terms and require prompt reporting and investigation of suspected abuse, including completion of documentation forms, witness statements, and notification of the Administrator and other entities. Despite these requirements, there was no formal investigation initiated at the time of the incident between R11 and R12. The NHA acknowledged that there was no formal investigation and stated that he only completes paper documentation if an incident is considered reportable, and that he does not always document situations he looks into if everyone appears fine. He also stated that he would report resident-to-resident physical altercations, and verbal altercations only if emotional or mental distress is noted, and confirmed there was no documentation of what was actually said during the altercation. Review of the medical records and care plans for both residents showed no documentation of the altercation and no indication that an abuse investigation had been conducted. Interviews with staff further confirmed the lack of appropriate follow-through. The CNA who heard the incident described R11 yelling at R12 to shut up or R11 would help shut R12 up. The SSD reported being aware that R11 had yelled at R12 to shut up and stated she would not be surprised if R11 had made the threatening statement reported by the CNA. The DON stated that in cases of resident-to-resident altercations, the facility’s practice is to separate the residents and notify the NHA, who would conduct the investigation, but in this case no such documented investigation occurred. There were also no care plan interventions implemented to protect R11 from further verbal abuse by R12 or to address the ongoing pattern of R11 becoming irritated and yelling at R12, despite the facility being aware of these interactions and the requirement under federal guidance to investigate resident-to-resident altercations as potential abuse and to develop care plans to prevent recurrence.
Failure to Follow PT-Directed Hoyer Transfer Status and Update Care Plan
Penalty
Summary
A resident with multiple complex medical conditions, including kidney and pancreatic transplant status, immunodeficiency due to drugs, type 1 diabetes with complications, dementia, Charcot joints, left foot drop, and osteoporosis, was identified as being at risk for falls and requiring substantial/maximal assistance with transfers, dressing, and toileting. The resident’s MDS showed intact cognition, and the ADL care plan documented transfer assistance as “weight bearing assistance,” without specifying use of a Hoyer lift. The fall care plan included interventions such as Dycem in the wheelchair and transfer to bed for naps, and PT notes from January through mid-April documented that the resident required a Hoyer lift with two staff for transfers. A PT communication sheet also indicated the resident was dependent on two staff with a Hoyer mechanical lift. Despite these PT directives, staff continued to transfer the resident using a mechanical sit-to-stand lift and later with a two-person stand-pivot transfer, which conflicted with PT’s determination that the resident was not appropriate for sit-to-stand and could not safely bear weight on the lower extremities. The resident reported to the surveyor that they had previously been transferred with a sit-to-stand lift and then by two staff performing a stand-pivot transfer, and that this caused fear and led them to often refuse to get out of bed. During observation, the surveyor saw two slings in the resident’s room, one for a sit-to-stand lift that was reportedly no longer in use and one for a Hoyer lift, while a CNA stated the resident currently transferred with heavy assist of two, sometimes stand-pivot, and had previously used a sit-to-stand lift. Interviews with the ADON, PT staff, PTA, and DON revealed that therapy staff consistently considered the resident to be a Hoyer-lift transfer only and that the resident had “always” been a Hoyer lift case. The ADON acknowledged uncertainty about when PT assessed and discontinued the sit-to-stand and recognized that PT transfer status changes were not being promptly incorporated into the care plan or CNA Kardex. The DON confirmed that the resident was supposed to be transferred only with a Hoyer lift and that the care plan still reflected “weight bearing assistance” rather than Hoyer use. An audit of transfer statuses provided to the surveyor did not identify this resident as affected, and the resident’s care plan and transfer status discrepancies were not captured in the facility’s audit process, resulting in staff not having accurate written guidance on the required Hoyer lift transfers.
Failure to Follow Daily Weight Orders and Provide Timely RD Assessment for Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutritional status for a resident receiving enteral nutrition and to follow physician orders for daily weights. The resident was admitted with multiple significant diagnoses, including CHF, acute kidney failure, dysphagia, and hemiplegia, and received nutrition via tube feeding. Admission orders from the discharging clinic directed that the resident be weighed daily at 5 a.m., but after an initial weight of 115.2 lbs on admission, no weights were documented from the following day through several weeks. When a weight was finally recorded on 3/6, it showed a loss of 11 lbs (9.55%) from admission, and there was no weight documented the next day despite ongoing orders for daily weights. The resident’s care plan identified nutritional risk related to CHF, CAD, dysphagia, need for tube feeding, and underweight BMI, with interventions to monitor intake, weight, skin, labs, diet tolerance, and hydration, and to notify the MD of significant weight changes. The care plan was later revised to include daily weights and to address a triggered 10% weight loss in 30 days. Despite this, there were additional gaps in daily weight documentation on specific dates, with no recorded refusals. Subsequent weights showed continued decline, including a weight of 92.0 lbs on 3/16, indicating a 20.14% loss from admission. Nursing progress notes also documented that the resident turned off the tube feeding, and the DON later stated the resident frequently stopped tube feedings and resisted water flushes, though CNA charting did not document diarrhea as described by the DON. The facility’s own Enteral Nutrition policy required that a dietician assess residents receiving enteral feedings and, if not available prior to the first feeding, that the on-call dietician be contacted to review admission information and determine initial orders. However, the resident did not receive a registered dietician assessment until 3/13, seven days after the significant weight loss was identified. The only documented dietician note was dated 3/13 and referenced recent weight loss and an underweight BMI. The DON acknowledged that daily weights were not started with admission despite the physician’s order and stated that the facility initially followed admission orders and involved the dietician only after the resident began losing weight, which conflicted with the written policy requiring dietician assessment at admission for residents on enteral feedings.
Failure to Provide Ordered IV Therapy and PICC Line Care
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate IV therapy and PICC line care in accordance with physician orders, the resident’s care plan, and professional standards of practice for one resident. The resident was re-admitted with a PICC line and multiple serious diagnoses, including end stage renal disease, abdominal pelvic abscess on chronic IV daptomycin therapy, dependence on dialysis, history of sepsis, and other complex conditions. The care plan and physician orders required regular IV antibiotic administration, routine PICC line flushing, dressing changes, monitoring of the PICC site, and measurement of arm circumference and external catheter length. These orders were intended to support ongoing treatment of the resident’s chronic pelvic abscess and to maintain PICC line patency and integrity. Record review showed that from early February through early April, normal saline flushes ordered every 8 hours were not consistently administered and were often documented as not given, held, or left blank on the MAR, indicating they were not performed as ordered. Required PICC-related assessments and care were also missed or undocumented: arm circumference above the insertion site was not documented or completed on specified dates, external catheter length was not documented or completed on a required date, and PICC needless connector changes were not documented or completed on two ordered dates. IV daptomycin doses ordered for administration after dialysis on specific Mondays, Wednesdays, and Fridays were not administered on multiple ordered days. Additionally, although the MAR showed that PICC dressing changes were documented as completed on three separate dates in March, a photograph dated later in March showed the PICC dressing still bearing a date and initials from mid-March, indicating the dressing had not been changed every 7 days as ordered. Further, hospital documentation from early April stated that the resident, known for a non-operable chronic pelvic abscess on chronic antibiotics and frequent admissions for sepsis, was brought to the ER minimally responsive, and that the PICC line had been accidentally removed at the nursing home sometime in the prior 24 hours. The EMT report from that day did not indicate a PICC line in place during transport. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for PICC care. One LPN stated that dialysis usually completed all PICC care and reported not doing anything with the PICC line, despite the LPN’s initials appearing on the MAR for PICC flushes, external catheter length measurements, and dressing changes, with some entries marked as not administered. The LPN could not explain why their initials appeared on the MAR. An RN reported that the PICC functioned well and believed, but was not certain, that the PICC was in place before transfer. The DON stated there were no progress notes indicating accidental PICC removal or malfunction and was unaware of the missed PICC care tasks and discrepancies between MAR documentation and the dated dressing shown in the photograph. The DON confirmed that staff were expected to complete all provider orders as written and to notify leadership and the provider if orders could not be followed. The combination of missed IV flushes, missed or undocumented PICC assessments and connector changes, missed IV antibiotic doses, inaccurate or conflicting MAR documentation, and lack of clear recognition or reporting of PICC line issues prior to hospital transfer constituted the failure to ensure the resident received IV therapy and PICC care consistent with physician orders, the care plan, and professional standards of practice.
Failure to Monitor Dialysis Resident’s Fistula, Weights, and Vitals as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis care and monitoring consistent with professional standards, the resident’s care plan, and physician orders for a resident with end-stage renal disease and a left forearm fistula. The facility’s own policy on care of residents with ESRD requires staff education on ESRD management, daily/shift assessments, recognition of complications, and care of shunts and fistulas, and states that the comprehensive care plan will reflect dialysis-related needs. The resident’s care plan and physician orders specified dialysis three times weekly, monitoring of the left forearm fistula for thrill and bruit, not drawing blood or taking blood pressure in the graft arm, daily weights with pre- and post-dialysis weights on dialysis days, and vital signs on Monday, Wednesday, and Friday with notification of the provider for abnormalities. Record review showed that these ordered assessments and monitoring were not carried out or documented. The surveyor could not find documentation in the MAR, TAR, progress notes, or other records that the resident’s left forearm fistula was assessed as ordered, including monitoring for thrill and bruit or site concerns. The surveyor also could not find evidence that pre- and post-dialysis weights were obtained every Monday, Wednesday, and Friday as required; only a few scattered weight entries over several weeks were present, rather than consistent dialysis-day pre/post weights. Additionally, vital signs were not assessed and documented every Monday, Wednesday, and Friday pre and post dialysis as ordered for management of dialysis treatments and hypertension medications. The surveyor identified specific instances of abnormal blood pressure readings (186/105 mmHg and 197/96 mmHg) without documentation that the on-call provider was notified or that any interventions were implemented. Interviews with staff further demonstrated inconsistent understanding and implementation of the required dialysis-related assessments. An LPN stated that they did not do anything with the resident’s fistula, believing it to be outside their scope of practice, while an RN and the DON described expectations that staff assess the fistula, perform head-to-to-toe assessments, obtain vitals and weights, and document findings on a Dialysis Communication Form. When the surveyor requested these forms for the review period, only a limited number were produced, and the DON acknowledged that staff were not accurately monitoring the resident’s care pre and post dialysis treatments as ordered.
Failure to Measure and Administer Correct Dose of Topical Voltaren Gel
Penalty
Summary
The deficiency involves the facility’s failure to ensure a medication error rate of 5% or less, as evidenced by 1 error out of 10 observed medication opportunities, resulting in a 10% error rate. A resident with low back pain, difficulty walking, spondylopathy of the lumbosacral region, and pain in the left shoulder and left knee had an order for Voltaren 1% gel to be applied to the left knee twice daily, not to exceed 4 g per application, 16 g per joint per day, or 32 g total per day. The resident had moderate cognitive impairment, was forgetful at times, but could make needs known and had clear, understandable speech. During a medication pass, a CMA prepared the Voltaren gel by squirting two lines of gel into a plastic medication cup without using any measuring device or dosing card, then applied part of the gel to the resident’s left knee and the remainder to the resident’s back, despite the order specifying use for the left knee. In subsequent interviews, the CMA stated that he did not know how many grams he was administering, believed the order did not specify how much to apply, and reported he had been taught to put one squirt in the cup for each area, applying only a thin layer. He also stated he did not think the medication cup could be used to measure the dose and that no one at the facility had instructed him otherwise, and he had never seen the Voltaren dosing card. The DON stated that nurses should verify the correct medication with the MAR before administration and that topical medications were generally applied as a thin layer, and she was unsure how staff ensured correct dosages for topical medications. When asked specifically about Voltaren gel, the DON stated she did not think there was anything different about its administration and was not aware of the dosing card or printed dosing instructions on the Voltaren box. Later review of the stock Voltaren revealed the dosing card inside the carton, which the DON stated she had never seen.
Failure to Obtain Consent and Inform Residents Regarding In‑Room Audio/Video Surveillance
Penalty
Summary
The facility failed to treat two residents with respect and dignity and to promote their quality of life by not properly managing audio and visual surveillance in their shared room. One resident with moderate cognitive impairment, who had a guardian appointed to assist with decision making, was admitted to a room already containing a video monitoring camera placed by the roommate’s activated POA. The camera was located on top of the roommate’s closet, pointed toward the corner of the roommate’s side of the room, and had audio capability. The facility did not have access to the surveillance, but the roommate’s POA could observe both video and audio, allowing them to hear conversations occurring anywhere in the room, including those involving the cognitively impaired resident. Surveyor review of records found no evidence that the cognitively impaired resident or the resident’s guardian had been informed of or consented to the presence of the camera, and no documentation that this was discussed at a care conference, despite the NHA’s statement that Social Services had done so. The guardian confirmed she was not aware of the camera and was not comfortable with it being in the resident’s room. Additionally, there was no consent in the roommate’s record for the camera, despite an email chain months earlier indicating the need for such consent from the roommate’s POA. Neither resident’s care plan included any information or interventions related to the video surveillance in their room.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current fall risk interventions following multiple falls. The resident was admitted after hospitalization for increased confusion and falls at home, had a BIMS score indicating moderately impaired cognition, and had an activated POA for decision-making. Initial assessments documented no elopement risk and a low fall risk, and the care plan identified increased risk for falls related to deconditioning, ataxia, recent fall, muscle weakness, and noncompliance with transfer assistance, with interventions such as keeping the call light within reach and therapy evaluation and treatment. Despite this, the resident experienced several falls, including a fall with major injury resulting in a fractured pelvis and subsequent falls in the room. After each fall, new fall interventions were documented on eINTERACT forms and in progress notes, such as placing a “Call for Help” sign and removing the walker when the resident was in bed with the wheelchair at bedside, but these interventions were not incorporated into the resident’s care plan. Surveyor observations confirmed the presence of the “Call for Help” sign and the walker’s placement in the room, and staff interviews showed varying understandings of the resident’s fall interventions, including toileting after meals, use of a floor mat, and keeping the bed in the lowest position. The DON confirmed that fall interventions documented after each fall had not been added to the care plan and that nurses were responsible for updating the care plan after completing eINTERACT forms. The surveyor determined that the facility did not revise the resident’s care plan to reflect current interventions to reduce fall risk.
Failure to Prevent and Properly Treat a Heel Pressure Injury Leading to Stage 4 Ulcer and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury (PI) prevention and treatment consistent with professional standards of practice for one resident, resulting in the development and deterioration of a left heel PI. The resident was admitted after hospitalization for sepsis with multi-organ failure and had multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease stage 3, unspecified dementia, hypertension, and heart failure. The initial care plan identified the resident as at increased risk for pressure ulcer development and included interventions such as a pressure-reducing mattress, administering treatments as ordered, and using barrier creams with each incontinent episode. A comprehensive MDS indicated the resident was at risk for pressure ulcer development, but the surveyor could not obtain documentation of the assessment tool or score used to determine this risk. Subsequently, the resident developed skin integrity issues, including a Stage 3 pressure wound on the right medial buttock that was later resolved. Later, an SBAR form documented a new wound to the heel, described as an open area measuring 8 cm by 5 cm, with a bandage applied and pressure boots placed while in bed. The wound was actually on the left heel, but it was incorrectly documented as the right heel. At that time, there was no comprehensive wound assessment completed that described wound characteristics beyond basic measurements. A treatment order was entered on the TAR for the left heel to cleanse with normal saline, pat dry, apply foam dressing, and secure with Kerlix once daily at bedtime, with daily assessment of drainage, appearance, and surrounding skin. The surveyor could not find evidence of a comprehensive wound assessment for the left heel until a later date. When the wound care physician evaluated the resident, the left heel blister had ruptured and was an open wound with nonviable tissue and necrosis, and debridement was performed. The physician ordered a new treatment plan including Betadine and dressing changes twice daily and as needed, but the TAR was not updated and nursing continued the prior once-daily treatment without Betadine until a later date. The care plan was not updated to reflect the new left heel surgical wound or to include weekly treatment documentation and monitoring until well after the wound had developed. Facility nurses did not complete comprehensive wound assessments upon discovery of the new PI or between weekly physician visits, and the NHA stated the facility does not do comprehensive assessments, relying instead on SBAR forms, of which only one was completed for the new heel PI. Over time, the left heel wound progressed. Subsequent wound care notes documented changes in wound size and treatment modifications, including discontinuation of Betadine and initiation of Hydrofera Blue and other dressings. The resident was hospitalized and later returned with a Stage 4 pressure wound of the left heel, with specific measurements and new treatment orders including Hydrofera Blue, collagen powder, and hypochlorous acid solution. An additional hospital order directed topical Tobramycin Sulfate Injection solution to the left heel twice daily. Later, the resident was again sent to the ER for chills and rigors, with the wound gently packed and the physician noting the resident appeared septic with tachypnea and tachycardia. Hospital records documented sepsis secondary to streptococcus dysgalactiae bacteremia and left calcaneal osteomyelitis, with diagnoses including an open wound and Stage 4 PI of the left heel. The surveyor concluded that the facility failed to implement aggressive interventions to prevent PI development, failed to ensure treatment orders were transcribed and completed as ordered, and failed to complete comprehensive assessments upon discovery and during the course of the left heel PI, leading to an avoidable PI that deteriorated to Stage IV with osteomyelitis requiring hospitalization and IV antibiotics. Interviews with facility leadership confirmed these failures. The DON acknowledged that wound care orders from the wound care physician were not followed, the care plan was not updated, and that the expectation was for nurses to complete and document ordered wound treatments and update the care plan for changes and new interventions. The DON also stated that comprehensive wound assessments were performed by the wound care physician, which explained the lack of comprehensive wound assessment documentation by facility nurses. The NHA, when asked why comprehensive assessments were not completed with the development of the new heel PI and changes in treatment, stated that the facility does not do comprehensive assessments and instead uses SBAR forms for changes in residents, despite only one SBAR being completed for the new heel PI. These documented inactions and omissions formed the basis of the deficiency and the finding of immediate jeopardy.
Removal Plan
- Facility initiated education for all licensed nursing staff (RNs and LPNs) including: prompt identification and reporting of new pressure injuries; completion of comprehensive assessments upon discovery of a new pressure injury; completion of daily diabetic foot checks; accurate transcription, initiation, and completion of physician ordered treatments; implementation of aggressive pressure injury prevention and treatment interventions per standards of practice; education on notification of physician/NP of all new pressure injuries as well as any significant changes to pressure injuries.
- Licensed nursing staff completed competency validation related to pressure injury staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions.
- Facility conducted skin assessments and Braden scale assessments of all residents in the facility.
- Facility conducted TAR audits of residents to ensure wound treatments were completed as ordered.
- Facility reviewed resident wound treatment orders to ensure they were accurate and appropriate.
- Facility conducted wound round audits on all residents with wounds/pressure injuries.
Failure to Ensure Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Review of the PBJ Staffing Data Report for Quarter 4 of 2025 (July 1–September 30) showed four days within the quarter with no RN hours reported: 08/15/2025, 09/08/2025, 09/09/2025, and 09/14/2025. Further review of the facility’s staff schedules and nurse postings for the last 92 days of that quarter confirmed that on 08/15/2025 (Friday), 09/08/2025 (Monday), and 09/09/2025 (Tuesday), there was no RN scheduled for eight consecutive hours. The facility was unable to provide documentation to support that an RN worked at least eight consecutive hours on those three dates. During interviews on 01/14/2026, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing sheet in the morning after updating the census, and that the facility does not manually update the public posting to reflect subsequent staffing changes, relying instead on the internal schedule, which is not publicly posted. Later that day, the Assistant Nursing Home Administrator provided documentation supporting RN coverage for 09/14/2025 and stated that corporate RNs had been rotating to provide the required eight hours of RN coverage between 08/15/2025 and 09/14/2025. However, no additional records or documentation could be produced to verify RN coverage for 08/15/2025, 09/08/2025, and 09/09/2025, resulting in a finding that the facility did not ensure RN coverage for at least eight consecutive hours on those dates for all 47 residents.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold notices and transfer/discharge notices to residents or their representatives in connection with hospital transfers. Record review and interviews showed that five residents did not receive proper notification of the facility’s bed-hold policy, including information on reserve payment, and did not receive notice before transfer or discharge indicating the specific reason for the transfer/discharge. One cognitively intact resident (R43), who scored 15/15 on the BIMS, was transferred to the hospital on 1/5/26 with a summary sent, but the social worker reported there was no bed-hold notice for this transfer. Another resident (R8), with moderate cognitive impairment (BIMS 9/15), was admitted to the hospital for hip pain related to an injury of unknown origin, and there was no bed-hold notice provided to the resident or representative for that transfer. Additional residents were similarly affected. One resident (R7) was transferred to the hospital for change in condition on two separate occasions and did not receive a notice of bed-hold indicating reserve payment or a notice before transfer/discharge stating the specific reason for the transfer/discharge. Two cognitively intact residents (R2 and R14), each scoring 15/15 on BIMS, had bed-hold forms signed by care managers from managed care organizations indicating they wished to reserve their rooms; however, R2’s bed-hold notice did not include the daily rate for reservation, and R14 did not receive a bed-hold notice for a subsequent hospital transfer. During the survey, the social worker responsible for transfers was unavailable due to illness, and the assistant nursing home administrator reported not being aware of the transfer/discharge process and needed to consult the nursing home administrator, but no follow-up was provided by survey exit.
Failure to Protect a Resident From Misappropriation of Personal Property and to Conduct Required Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to follow its abuse and misappropriation investigation and reporting policies. On 01/07/26, the facility was made aware that a resident (R29) was missing multiple personal items, including a cell phone, cell phone charger, wallet containing $80.00, tennis shoes, two grabbers, and a wicker/wooden box with household items such as keys. The facility’s own policies stated that residents have the right to be free from misappropriation of property and that all reports of misappropriation must be promptly reported to local, state, and federal agencies and thoroughly investigated. Despite this, the facility did not protect the resident from misappropriation, did not report the allegation to the State Agency, and did not begin an investigation until 01/09/26. When the surveyor reviewed a complaint submitted to the State Agency by the resident’s family member on 01/08/26, the family member confirmed the list of missing items and stated she had filed two grievances with the facility and also reported the incident to law enforcement. Review of the facility’s grievance log for the prior three months showed only one grievance for this resident, dated 10/06/25, unrelated to missing property, and the facility did not provide its grievance policy when requested. Over several days, the surveyor repeatedly requested the facility’s internal investigation of the missing property; the facility did not provide any investigation documentation until 01/13/26, at which time only a single Grievance/Complaint form dated 01/07/26 was produced. That form showed the grievance was assigned on 01/09/26 and documented that staff searched the resident’s room and laundry and were waiting for the daughter to call back to make a plan to replace items. The facility was unable to locate the missing property and did not provide any additional information indicating that required interviews or a thorough investigation had been conducted.
Failure to Thoroughly Investigate Missing Property and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into allegations of abuse and misappropriation of resident property for two residents. For one resident, the facility was notified that personal property, including $80 in cash, was missing. Although the grievance was reportedly filed by the family member, the facility did not begin its investigation until two days after being made aware of the missing items. The only documented investigative action was a grievance/complaint form indicating that staff searched the resident’s room and laundry, waited a couple of days, rechecked laundry, and then contacted the resident’s daughter about replacing the items. No documentation was provided to show that staff or other residents were interviewed, and the facility was unable to locate the missing property. The surveyor requested the facility’s internal investigation multiple times over several days and was only provided the single grievance form, with no additional investigative documentation. For the second resident, the deficiency centers on the facility’s incomplete investigation into a pelvic fracture of unknown origin. This resident had a history of falls and multiple fall-related care plan interventions, and had moderate cognitive impairment as evidenced by a BIMS score of 9/15. On the morning in question, the resident began to complain of pain but initially denied falling. A progress note, lacking date, time, and author, documented that the resident complained of left hip pain, denied any falls during the night, was given acetaminophen, and that an x-ray was ordered. Due to weather-related delays with mobile x-ray, the resident was sent to the ER, where imaging revealed a markedly comminuted fracture of the left acetabulum and a nondisplaced fracture of the left inferior pubic ramus, with associated hemorrhage. The facility’s investigation into the resident’s injury did not meet its own policy requirements for a thorough abuse or injury-of-unknown-source investigation. The investigation worksheet identified two staff members, an LPN and a CNA, as involved or potential witnesses, and only these two staff were interviewed. The LPN reported finding the resident partially off the bed and assisting the resident back to bed without signs of pain, and the CNA reported responding to the resident’s calls during the night, noting restlessness but no complaints and that the resident was asleep when the Foley catheter was emptied. The worksheet documented that no interview was conducted with the resident by facility staff, that a complete physical and emotional assessment identifying areas of injury was not completed, and that there were no new interventions or clear conclusions about how or why the incident occurred. It also noted that documentation in the resident record was not complete and left sections regarding root cause, care plan revisions, and other corrective actions unanswered. The nursing home administrator confirmed that the paperwork submitted to the state constituted the entirety of the 5-day investigation and that no additional investigation was performed. Across both examples, the facility’s actions did not align with its written policies on abuse prevention and abuse investigation and reporting, which require prompt reporting, thorough investigation, and interviews with the resident, the reporter, witnesses, and staff on all shifts who had contact with the resident during the relevant period. In the case of the missing property, the facility did not document interviews or a comprehensive inquiry into the alleged misappropriation. In the case of the pelvic fracture, the facility did not complete a full assessment, did not interview the resident, did not identify a root cause, and did not fully document the incident in the medical record, resulting in an incomplete investigation of a serious injury of unknown source and failure to rule out abuse as required by policy.
Failure to Follow Wound Care and Blood Pressure Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide wound care and monitoring according to professional standards for two residents. One resident with chronic osteomyelitis, bilateral foot ulcers with necrosis of bone, toe amputations, diabetes, and sepsis was admitted with active treatment orders on the TAR for nightly and as-needed dressing changes to bilateral lower extremities, including monitoring for infection, documenting drainage, and documenting pain scores. The resident’s initial care plan did not address wounds or wound care interventions. Surveyor review of the TAR showed no documentation of daily assessments or dressing changes from 1/5/26 to 1/10/26, despite the active orders. When observed, the resident’s foot dressings were loosely wrapped, and the resident reported having wounds on both feet and not believing dressing changes had been done since admission. An LPN stated the dressing changes were done as needed and would be documented in the TAR, but the TAR lacked entries for the specified dates. The DON confirmed that the TAR orders required daily dressing changes and that documentation only showed dressing changes on 1/11 and 1/12/26, indicating the dressings were not changed on 1/5 through 1/10/26. The second resident, with hypertension, chronic kidney disease, and cognitive decline, experienced a fall from a recliner and was found on the floor, incontinent but alert and oriented, with vital signs stable except for low blood pressure. The nurse documented that the NP was notified and instructed staff to push fluids and assess blood pressure every hour to determine if hospital transfer was needed, and to hold all blood pressure medications until blood pressure reached proper levels. The MAR showed antihypertensive medications were held on the day of the incident, and all medications were administered as ordered on the following two days, including the morning of 12/23/25. However, surveyor review could not locate documentation of blood pressure readings after the initial incident, nor documentation that medications were held as ordered beyond what appeared on the MAR. The DON stated she was unable to find documentation that nursing staff followed the NP’s orders to monitor blood pressure until it reached acceptable levels or that medications were held as directed.
Failure to Maintain Elopement Protection and Safe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistive devices for two residents. One resident with anxiety, depression, dementia, and severe cognitive impairment (BIMS 5/15) had been assessed as an elopement risk and care planned to wear a wanderguard on the left wrist, with orders and TAR documentation indicating staff were to check the device’s placement, function, and the skin around it every shift. The elopement assessment, care plan, and elopement binder all identified this resident as an elopement risk with a wanderguard in place. However, during surveyor observations and interviews on the same day, the resident was repeatedly observed without a wanderguard on the left wrist, left ankle, body, or wheelchair. Despite this, nursing documentation reflected that the wanderguard was being checked, and staff interviews showed uncertainty about whether the resident had a wanderguard on, with one CNA reporting that when taking the resident outside to smoke, no alarm had ever sounded. The second example concerns a resident with moderately impaired cognition (BIMS 5) who required substantial/maximal assistance for toilet transfers and had a care plan specifying a two‑person transfer with a gait belt. A surveyor observed this resident sitting on the toilet under the supervision of a CNA, with no gait belt in place. The CNA then performed incontinence care and transferred the resident independently to a wheelchair without using a gait belt. When questioned, the CNA stated that they had not been using a gait belt for this resident’s transfers and, after checking the care plan, stated that it did not indicate the need for a gait belt, despite the documented care plan approach requiring one.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted and updated, including the total number of hours and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, potentially affecting all 47 residents in the facility. On entrance to the facility, the surveyor observed that the Direct Care Report posted in the lobby was dated several weeks earlier and reflected a census of 47, indicating it was not current. Subsequent review of staff schedules and staff postings from early December through mid-January showed that schedules had multiple marked changes on specific dates, but the corresponding daily staff postings did not reflect accurate staffing numbers for several of those days. During an interview, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing information in the morning after updating the census, and that the daily posting is not manually updated when staffing changes occur, with changes only reflected on the internal daily schedules rather than on the publicly posted staffing information. No specific residents, medical histories, or clinical conditions were described in the report beyond the total facility census of 47 residents who could be affected by the inaccurate staffing postings.
Failure to Follow Hospital Discharge Wound Care Orders and Consult Physician
Penalty
Summary
A deficiency occurred when the facility failed to consult with a physician and follow hospital discharge instructions regarding wound care for a resident admitted after hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene. The resident, who had moderately impaired cognition, was discharged from the hospital with orders for a wound VAC (vacuum assisted closure) and vancomycin solution irrigation to be applied to a large right groin wound. Upon admission, these orders were not properly communicated or implemented by facility staff. Facility records and staff interviews revealed that the wound VAC and vancomycin solution were not available or administered as ordered. The admitting nurse, who was from an agency, did not ensure the wound care orders were entered or followed. Other nursing staff were unaware of the specific wound care requirements until several days after admission, and the vancomycin solution was never ordered. The wound VAC was not ordered until staff discovered documentation in the resident's room, and it was delivered two days after admission. During this period, the resident did not receive the prescribed wound care, and documentation of wound care was missing for several shifts. When the wound VAC was finally to be applied, staff discovered the resident's wound was contaminated with stool, and the resident was experiencing significant pain. The physician determined that the wound VAC had not been applied as intended and that the wound was at risk due to contamination. The resident was subsequently sent to the emergency room for wound care. Interviews with staff and review of records confirmed that the facility did not consult with a physician when unable to obtain the necessary wound care supplies and did not follow the hospital's discharge instructions for wound management.
Failure to Develop Baseline Wound Care Plan Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan for wound care within 48 hours of admission for a resident who was admitted following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin. The resident had a history of multiple debridements, extensive antibiotic therapy, and required a Foley catheter to maintain wound cleanliness. Upon discharge from the hospital, the resident had specific wound care orders, including the initiation of a wound VAC and vancomycin irrigation, as well as ongoing antibiotic therapy. Despite these complex medical needs and clear physician orders for wound care, the facility's care plan for the resident only included documentation for a Foley catheter and advanced directives, with no baseline care plan addressing wound care. This omission was confirmed during an interview with an LPN, who acknowledged that a baseline care plan for wound care had not been developed for the resident.
Failure to Provide Ordered Wound Care and Timely Wound VAC Application
Penalty
Summary
A resident was admitted to the facility following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin, with a significant wound requiring specialized care. Upon admission, the resident had physician orders for wound care, including the use of a wound VAC and vancomycin solution irrigation, as well as a Foley catheter to maintain cleanliness. However, the facility failed to implement a baseline care plan addressing the resident's wounds, and the wound care orders were not accurately or promptly entered into the treatment administration record (TAR). The only wound care documented was a single wet-to-dry dressing change, and there was no evidence that the vancomycin solution was ordered or administered as prescribed. The facility did not ensure the timely provision of a wound VAC, which was specifically ordered to prevent contamination of the wound with stool due to its location and severity. The wound VAC was not ordered until several days after admission, and it did not arrive until the morning the resident was sent back to the hospital. During this period, the resident's wound was left exposed and ultimately became contaminated with stool, as documented by both a physician assistant and a physician who assessed the resident. The lack of appropriate wound care and delay in obtaining the wound VAC resulted in the resident experiencing significant pain and required transfer back to the hospital for further treatment. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wound care needs and orders. The admitting nurse was from an agency and could not be interviewed, while other nursing staff were unaware of the specific wound care orders until documentation was found in the resident's room. The facility's documentation and assessment of the wound were also inaccurate, misclassifying the wound type and failing to measure it upon admission. No additional evidence was provided to support that the resident received the ordered care during the period in question.
Failure to Appoint RN as Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required by federal regulations. Instead, the DON position was filled by an LPN, and there was a period when the facility had no DON at all. This was confirmed through interviews with the Assistant Nursing Home Administrator and the Assistant Director of Nursing, both of whom stated that after the previous DON, who was an RN, resigned, there was a gap before the LPN was hired as DON. During this time, the ADON, also an LPN, was the only nursing leadership present. The surveyor reviewed multiple complaint investigations and the facility's grievance log during the period when the LPN was serving as DON. Several complaint investigations resulted in citations related to pharmacy services, food procurement, catheter care, bedhold, notice of transfer, Ombudsman notification, CPR, intravenous fluids, medication errors, and quality assurance activities. The grievance log showed a notable number of grievances filed during the months when the LPN was acting as DON, indicating ongoing concerns during this period.
Failure to Timely Request and Support Waiver for RN DON Requirement
Penalty
Summary
The facility failed to request a waiver in a timely and complete manner when unable to meet the requirement of having a registered nurse serve as the Director of Nursing (DON). After the resignation of the previous DON, who was a registered nurse, the facility was without a registered nurse in this position for an extended period. Although the facility eventually submitted a waiver request, it did so several months after the vacancy began. The State Agency (SA) denied the initial waiver request and requested additional information to demonstrate diligent efforts to recruit appropriate personnel, evidence that a waiver would not endanger resident health or safety, and confirmation that a registered nurse or physician was available to respond to calls when licensed nursing services were unavailable. The facility did not respond to the SA's request for further information, nor did it submit an additional waiver request as instructed. During an on-site investigation, it was confirmed that the acting DON was not a registered nurse and did not meet state and federal requirements.
Call Light System Failure Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call light system was fully operational in all resident areas, including bathrooms and bathing areas. Observations revealed that call lights on all resident halls were activated but not sounding, and the system at the nurse's station was not alerting staff when call lights were activated. Multiple interviews with residents, family members, and staff confirmed that the auditory alarms had not been functioning for approximately five weeks, and that staff were not being notified of call lights at the nurse's station. Residents reported long wait times for assistance, sometimes up to an hour, and family members observed staff taking up to 40 minutes to respond to call lights. Some residents had to leave their rooms and call out in the hallway to get help. The Assistant Director of Nursing and the Assistant Nursing Home Administrator both confirmed the lack of auditory alerts, with the latter stating that she was told the system was considered functional as long as the lights worked. Maintenance staff reported ongoing issues with obtaining replacement parts for the outdated system, with several unsuccessful attempts to repair it using refurbished components. Documentation provided included invoices and delivery records for replacement parts, and the facility's grievance log showed five complaints related to call lights in the previous month.
Delay in Initiating CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to ensure that cardiopulmonary resuscitation (CPR) was provided immediately when a resident was found unresponsive. The resident, who had diagnoses including gram-positive bacteremia, Parkinson's disease, seizure disorder, and difficulty walking, was documented as a full code in both physician orders and the care plan, indicating that all life-saving measures, including CPR, should be performed in the event of cardiac or respiratory arrest. The care plan specifically stated that the resident's code status should be honored and that CPR should be initiated in the event of a code. On the day of the incident, a CNA discovered the resident unresponsive, face down, and not breathing, with no visible or audible signs of life. The CNA did not call for help from within the room but instead left to find a nurse. The LPN who responded also found the resident unresponsive and without a pulse, and instructed the CNA to get the RN and to call 911. CPR was not initiated until the RN arrived and, with assistance, repositioned the resident to the floor. The RN then began chest compressions, and the LPN provided breaths with an Ambu bag. The delay in starting CPR was confirmed by interviews and documentation, as CPR was not started until after the RN entered the room and the resident was repositioned. Facility policy required that staff check for responsiveness, breathing, and pulse, call for help, activate emergency response, and start CPR immediately if no pulse or breathing was detected. Interviews with facility leadership confirmed that the expectation was for CPR to be started as soon as possible, in accordance with policy and the resident's full code status. The delay in initiating CPR was contrary to these expectations and the facility's written procedures.
Failure to Document and Order PICC Line Care for IV Administration
Penalty
Summary
A resident with a history of gram-positive bacteremia and moderately impaired cognition was admitted to the facility with a peripherally inserted central catheter (PICC) line for IV antibiotic administration. The resident's hospital discharge summary indicated the PICC line was placed prior to transfer, and IV antibiotics were administered through this line. However, review of the clinical physician orders, medication administration records (MARs), and treatment administration records (TARs) revealed there were no documented orders or records for routine PICC line care, including site monitoring, flushing to maintain patency, or dressing changes. Progress notes also lacked documentation of these essential PICC line care activities. Staff interviews confirmed that there were no standing orders for PICC line care on the resident's records, and the facility's policy required physician orders for IV fluids and site monitoring. The resident ultimately experienced a PICC line occlusion, resulting in a transfer to the emergency room, where the line could not be unclogged and was replaced with a midline catheter. The absence of documented orders and care for the PICC line constituted a failure to provide safe and appropriate administration of IV fluids and line maintenance.
Failure to Administer Medications at Prescribed Times
Penalty
Summary
The facility failed to administer medications as scheduled for two of five residents reviewed for pharmacy services. For one resident with severe cognitive impairment and multiple diagnoses, including generalized anxiety disorder and neurocognitive disorder, medication administration records showed that clonazepam and baclofen were not given at the prescribed times. Doses were administered several hours late or too close together, with some doses given less than an hour apart, contrary to the scheduled intervals. Observations confirmed that medications were administered outside the prescribed timeframes. Another resident, who was cognitively intact and had diagnoses of mood disorder and major depressive disorder, also did not receive medications as scheduled. Buspirone and gabapentin, both ordered three times daily, were administered hours late or with insufficient intervals between doses. Medication administration records and direct observation documented these timing discrepancies. Interviews with staff revealed a lack of consistent understanding and adherence to medication administration timing policies. A certified medication aide stated that medications could be given within a one-hour window of the scheduled time, but did not check the last administration time for medications given multiple times a day. The assistant director of nursing and director of nursing described a more liberalized approach to medication timing, but were unclear on procedures for medications scheduled more than once daily. Facility policy required medications to be administered within one hour of the prescribed time, unless otherwise specified, but this was not followed.
Missed Doses of IV Antibiotic Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that Vancomycin, an IV antibiotic, was administered as ordered for a resident diagnosed with gram-positive bacteremia. The resident was admitted with a history of receiving IV antibiotics in the hospital, and the discharge orders specified daily Vancomycin administration. Upon admission, the facility received an order to start Vancomycin on a specific date and time, but the medication was not available in the facility for two consecutive days. Documentation showed that the pharmacy was contacted and the order was refaxed, with the pharmacy indicating the medication would be delivered that night, but the first dose was not administered until two days after the scheduled start date. The electronic Medication Administration Record (eMAR) and progress notes confirmed that Vancomycin was not administered on the first two scheduled days, and the first dose was given on the third day. The nurse practitioner responsible for the resident was not informed of the missed doses and stated that he would have taken additional steps if he had been notified. The facility's policy required medications to be administered in a safe and timely manner, within one hour of the prescribed time unless otherwise specified, but this was not followed in this instance.
Failure to Investigate and Review Adverse Event Resulting in Resident Death
Penalty
Summary
The facility failed to identify and investigate an adverse event involving a resident who was found unresponsive with her chin and neck pressed against the bed frame, her lower body on the floor, and required CPR according to her code status. The resident had a history of Parkinson's disease, seizure disorder or epilepsy, difficulty walking, and moderately impaired cognition. Staff interviews revealed that the resident was discovered in a face-down, back-bending position, and was unresponsive with no pulse or breathing detected. Despite the circumstances, no incident report was created for this event, and there was no evidence of a Quality Assurance and Performance Improvement (QAPI) review or internal investigation by the facility's Quality Assessment and Assurance (QAA) committee. The facility's policies required the QAA committee to oversee the identification and handling of quality issues, including adverse events and negative outcomes related to resident care and safety. However, the committee did not identify the resident's death as an adverse event, did not initiate an incident report, and did not review or investigate the incident. The Regional Support Administrator acknowledged that a death from an injury of unknown origin should be considered an adverse event and reviewed by the QAA committee, but confirmed that this did not occur in this case.
Failure to Monitor and Document Catheter Output and Assess for Complications
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for residents with indwelling Foley and suprapubic catheters, resulting in inadequate monitoring and documentation of urinary output, as well as insufficient assessment and provider notification when abnormal findings were present. For three residents with catheters, there were repeated instances where urine output was either not documented, documented as zero without further assessment, or recorded with unclear or missing amounts. In multiple cases, there was no evidence that the provider was notified when urine output was absent for a shift, as required by physician orders and facility policy. One resident with a suprapubic catheter experienced two days of increased incontinence and lack of catheter drainage, which was not properly assessed or reported. The resident was ultimately transferred to the hospital and admitted with a severe urinary tract infection. Review of the medical record showed multiple shifts with zero urine output documented and no corresponding provider notification or additional nursing assessments, such as checking catheter patency, vital signs, or abdominal assessment. Interviews with nursing staff revealed a lack of clear parameters for when to notify providers and inconsistent understanding of required assessments when abnormal output was noted. For two other residents with indwelling catheters, similar deficiencies were observed. Documentation of urinary output was frequently missing, incomplete, or unclear, and there was no evidence of provider notification or further assessment when output was zero or not recorded. Facility policies and professional standards require accurate monitoring and reporting of catheter output to prevent complications, but these were not consistently followed, as evidenced by the surveyor's review of records and staff interviews.
Failure to Provide Required Transfer Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers for three residents. Specifically, when residents experienced a change in condition and were transferred to the hospital, the facility did not provide a Notice of Bedhold or a written Notice of Transfer to the residents or their representatives. Additionally, there was no documentation that the Ombudsman was notified of these transfers. This deficiency was identified through record review and interviews, which confirmed the absence of these required notifications for all three residents involved. One resident with an activated Power of Attorney was transferred to the hospital on two separate occasions following falls, but neither a Bedhold notice nor a Notice of Transfer was provided to the representative, and the Ombudsman was not notified. Another resident with a legal guardian was transferred to the hospital without the required notifications being given. A third resident, who was her own decision maker and had diagnoses of multiple sclerosis and neurogenic bladder, was also transferred to the hospital without documentation of a Bedhold notice, written transfer notice, or Ombudsman notification. The Nursing Home Administrator confirmed that these notifications were not provided and was unaware of the requirements for issuing them at the time of each transfer.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were properly stored and labeled according to professional standards. In the medication storage room, a bottle of lorazepam prescribed to a resident was found in an unlocked refrigerator, despite being labeled as opened on 12/01/24 and identified as expired by the Director of Nursing (DON). Additionally, two open bottles of eye drops were found in a larger refrigerator without proper labeling or open dates, with only 'AM' and 'PM' written on the sides. The DON acknowledged that these medications should have been labeled. Further inspection of the medication storage room revealed four opened boxes of intermittent catheters, three of which had expiration dates of 05/31/2020 and one with 07/05/2020. The DON confirmed these supplies were expired and should not have been stored in the cabinet. Interviews with staff, including a Certified Medication Aide (CMA) and an LPN, demonstrated a lack of knowledge regarding the identification of expired supplies and the proper storage of medications, including the requirement for locked storage and appropriate labeling.
Failure to Monitor and Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure continued monitoring of internal food temperatures as required by its policy, which states that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, with temperatures properly recorded prior to each meal service. During observation, kitchen staff loaded and served trays to residents in two hallways, with the last tray served containing over-easy eggs measured at 107.2 degrees Fahrenheit, well below the required temperature. The eggs were placed on the tray directly from the grill without an internal temperature check, and staff were unaware of the eggs' temperature prior to service. Resident council meeting minutes previously indicated concerns with food being served late, and while food logs showed temperatures taken at the beginning and end of service, there was no evidence of temperature monitoring during the meal service. The resident who received the eggs had no complaints and consumed the meal.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for two of four sampled residents. In one case, a resident admitted after hip surgery with multiple diagnoses, including high cholesterol, coronary artery disease, parkinsonism, and cognitive impairment, had a physician order for Aspirin 81mg twice daily to prevent clotting. However, the medication order was incorrectly transcribed into the electronic Medication Administration Record (eMAR) as 81mg once daily, resulting in the resident not receiving the prescribed dose for several weeks after admission. The error was only corrected weeks later, and the resident did not receive the correct dosing until that time. In another instance, a resident with paralysis, nerve pain, osteoarthritis, hypertension, and high cholesterol, who was dependent for mobility and activities of daily living, did not receive prescribed evening medications (Carbamazepine and Famotidine) on two separate occasions. The eMAR showed no documentation of medication administration, refusal, or the resident being out of the facility, and the required codes or progress notes were absent. Staff interviews confirmed that the medications were not administered and that the expected documentation was not completed.
Failure to Notify Provider of Positive Urinalysis Results
Penalty
Summary
The facility failed to ensure that a physician was notified of laboratory results for a resident who had a history of urinary tract infections, renal insufficiency, and chronic suprapubic catheter use. The resident was admitted with multiple urological issues and had recently undergone stent placement due to kidney stones. A urinalysis was ordered by the resident's urologist as part of pre-surgical planning for stent removal, and the urine specimen was collected and sent to the lab as ordered. When the urinalysis results were received, they showed significant growth of pathogens, specifically klebsiella variicola and proteus mirabilis. However, the facility did not update either the resident's primary provider or the urologist with these results. The order for the urinalysis was incorrectly placed under the facility's medical director rather than the urologist who had requested it, resulting in a lack of follow-up. Both the nurse practitioner and the urologist confirmed they were not made aware of the results, and the infection preventionist stated that a provider should have been updated with the results regardless of whether they were positive or negative. Four days after the urinalysis results were available, the resident experienced a change in condition, including dizziness, lethargy, and fever, and was subsequently hospitalized for sepsis. The discharge summary from the hospital indicated the resident was treated for septicemia, with possible sources including a catheter-associated urinary tract infection and pneumonia. Interviews with facility staff confirmed that the resident had no symptoms prior to the acute event, and the lack of provider notification regarding the urinalysis results was not explained by facility staff.
Failure to Update Facility Assessment and Staffing Levels
Penalty
Summary
The facility failed to update its facility-wide assessment to reflect the current resident care needs and the resources required to support these needs. The assessment, last revised on 01/01/25, did not account for a significant increase in resident census from the mid-30s to 48 residents, following 18 new admissions over a 21-day period. The staffing ratios outlined in the assessment were based on the previous census and did not accommodate the increased number of residents, leading to insufficient staffing levels. Interviews with staff, including CNAs and RNs, revealed that the rapid increase in admissions was not matched by an increase in staffing, resulting in each CNA being responsible for 16 to 18 residents during the day and over 20 at night. This staffing shortage made it difficult to safely care for residents, as CNAs often had to assist with two-person transfers, leaving other residents unattended. Scheduled showers were postponed, and staff reported resignations due to the stress of the increased workload and lack of administrative response to requests for additional help. RNs also reported challenges in managing the increased workload, with responsibilities including medication administration, treatments, assessments, and new resident admissions. The delay in medication, treatment, and assessment completion was noted, and staff expressed concerns about missing changes in residents' conditions due to time constraints. The Nursing Home Administrator acknowledged that the facility assessment had not been updated to reflect the increased census and staffing needs, indicating a lack of proactive planning in response to the facility's efforts to increase its resident population.
Failure to Provide Comprehensive Care Leads to Hospitalizations
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice and the residents' comprehensive person-centered care plans for two residents. Resident R21, who had a history of congestive heart failure (CHF) and other cardiac conditions, did not receive comprehensive CHF assessments or necessary lab tests to monitor their condition. Despite showing symptoms of shortness of breath and nausea, the facility did not complete the ordered Basic Metabolic Panel (BMP) and B-type Natriuretic Peptide (BNP) tests. This oversight led to R21 being hospitalized with an exacerbation of CHF and a Non-ST segment elevation myocardial infarction. Resident R6, who had multiple non-pressure wounds, did not receive timely and comprehensive skin assessments. The facility failed to conduct a comprehensive skin assessment upon R6's admission and did not perform weekly assessments as required. Additionally, R6 missed wound care appointments, and there was no evidence of follow-up or communication with the wound care clinic regarding missed appointments or changes in R6's condition. This lack of proper wound care management contributed to R6's hospitalization and subsequent amputation due to necrotic wounds. Interviews with facility staff, including the Director of Nursing (DON) and Registered Nurses (RNs), revealed a lack of adherence to the facility's policies and procedures for monitoring and documenting residents' conditions. The DON acknowledged the absence of comprehensive assessments and the failure to notify providers of changes in residents' conditions. The facility's inability to ensure proper care and treatment for residents R21 and R6 resulted in actual harm, as evidenced by their hospitalizations and deteriorating health conditions.
Improper Food Handling and Sanitization Practices
Penalty
Summary
The facility failed to ensure proper sanitization and food handling practices, which could potentially lead to foodborne illnesses among all 28 residents. Observations revealed that serving utensils were improperly stored in thickener powder, and cooks were seen handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. Additionally, cooks did not perform hand hygiene between glove changes during food service, and hair restraints were not worn correctly by staff entering the kitchen, preparing, or serving food. Further observations indicated that food items, such as milk, were placed in the kitchen refrigerator without being labeled with an opened date, increasing the risk of foodborne illnesses. The facility's policy on preventing foodborne illness was not adhered to, as employees failed to wash their hands before handling food, after touching soiled equipment, and during food preparation. The use of gloves was not managed properly, as they were not changed after contamination, and hand hygiene was not performed before putting on new gloves. The facility's refrigerator and freezer contained several unlabeled and undated food items, including leftovers and opened food containers, which were not monitored or discarded as per the facility's policy. Interviews with staff, including the Nursing Home Administrator and Director of Nursing, confirmed that the expectation was for all food items to be labeled and dated, and for kitchen staff to routinely monitor and discard undated or expired items. However, these practices were not consistently followed, leading to the observed deficiencies.
Failure to Notify Physician of Resident's Transfer to ED
Penalty
Summary
The facility failed to immediately notify a resident's physician when the resident experienced difficulty breathing and was transferred to the Emergency Department (ED) via Emergency Medical Services (EMS). This deficiency was identified for a resident who had been admitted with multiple diagnoses, including congestive heart failure and myocardial infarction. The resident had been experiencing shortness of breath for several days before being sent to the hospital in the middle of the night. Upon review, it was found that there was no documentation indicating that the resident's physician was informed of the transfer to the ED. The Nurse Practitioner (NP) was not notified of the resident's condition and transfer until the following day, which led to the resident's admission to the hospital. The Director of Nursing (DON) confirmed that there was no notification to any providers about the resident's change in condition and transfer, which was against the expected standard practice of notifying the physician within 15-30 minutes of a change in condition.
Failure to Conduct PASRR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to conduct a Preadmission Screening Resident Review (PASRR) Level II screen for a resident with a serious mental disorder who was taking psychotropic medication. This oversight was identified during a review of the resident's records and an interview with the Nursing Home Administrator. The resident, who was admitted with a diagnosis of schizoaffective disorder, was prescribed medications including Haldol, ziprasidone, and sertraline. A Level I PASRR screening indicated the need for a Level II screening due to the resident's major mental disorder and use of psychotropic medications. Despite the completion of form F-20822, which recommended nursing facility placement with a short-term exemption from a Level II screening, no specific short-term exemption option was selected. The form also noted that if the resident required nursing facility placement beyond the permitted timeframes of the short-term exemptions, a Level II screening was necessary. However, the surveyor could not locate a completed Level II PASRR screening in the resident's records, and the Nursing Home Administrator confirmed that it had not been completed.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident, identified as R21, who was at risk for pressure injuries and had existing pressure injuries upon admission. The facility did not apply the prescribed purple boots for off-loading heels as ordered, and comprehensive skin assessments were not conducted consistently. The resident was admitted with seven pressure injuries, but the facility did not document their locations, sizes, or stages, making it unclear whether any of the injuries progressed or were already at advanced stages upon admission. The resident's care plan included the use of purple heel protector boots at all times, but observations on multiple occasions showed that the resident was not wearing the boots while sitting in a wheelchair. Staff interviews revealed inconsistencies in applying the boots and documenting their application. The Director of Nursing acknowledged that staff had not been consistent in applying the boots, and a Certified Nurse Assistant admitted to not re-approaching the resident after an initial refusal to wear the boots. The facility also failed to conduct thorough pressure injury assessments, including documentation of the location, measurements, and condition of the injuries. The wound clinic notes indicated a lack of detailed assessments, and the facility did not complete pressure injury assessments from admission until July 1st. The surveyor was unable to determine the progression of the injuries due to the lack of documentation and numbering of the pressure injuries by the wound clinic and the facility.
Failure to Implement Resident's Ambulation Program
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's mobility, specifically for a resident identified as R10. The facility lacked a maintenance or restorative program, as confirmed by the Director of Nursing (DON), which contributed to the deficiency. R10's care plan included a recommendation for ambulation to maintain the current level of function and minimize fall risk, yet the staff did not implement this program. Observations by the surveyor showed that R10 was transported in a wheelchair to and from meals without being offered the opportunity to ambulate, contrary to the care plan instructions. R10's medical history includes frontotemporal dementia with agitation, COPD, anemia, depression with anxiety, CHF, tremors, subarachnoid hemorrhage, seizures, and incontinence. Despite these conditions, R10 was noted to have no range of motion impairments and required supervision with transfers. The surveyor found no evidence in R10's records that the walking program was conducted, and the DON confirmed that the program was not offered from July 1, 2024, to the present. A CNA caring for R10 indicated that she had not discussed the ambulation program with nursing or therapy staff, highlighting a communication gap regarding R10's care needs.
Failure to Assess Indwelling Catheter Removal
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter was assessed for its removal as soon as possible, as required by their policy. The resident, who was admitted with an indwelling catheter, had diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, urinary tract infection, and overactive bladder. Despite these conditions, the facility did not attempt a urinary toileting program or assess urinary continence due to the presence of the catheter. The facility's policy mandates that residents with indwelling catheters be assessed for removal upon admission, quarterly, and with any change in condition, but this was not done for the resident in question. The Director of Nursing (DON) acknowledged that the routine changing of catheters, as practiced by the facility, did not align with current standards of practice or the facility's policy, which recommends changing catheters based on clinical indications rather than at fixed intervals. The resident's care plan included a diagnosis of neurogenic bladder, which was not supported by documentation, and the catheter was changed every four weeks as per physician orders. The facility failed to provide additional documentation, such as urology visits or orders, to justify the continued use of the indwelling catheter, and the DON admitted that the resident's diagnoses did not meet the criteria for its use.
Infection Control Deficiencies in PPE Usage and Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents. In the first instance, a resident with an indwelling catheter was under Enhanced Barrier Precautions (EBP), which required staff to wear gowns and gloves during high-contact care activities. However, a Certified Nursing Assistant (CNA) was observed not wearing a protective gown while performing a task related to the resident's catheter care. The CNA acknowledged the expectation to wear appropriate Personal Protective Equipment (PPE) but admitted to skipping it to expedite the task. The Director of Nursing confirmed that staff are expected to adhere to facility policies to prevent infections. In the second instance, a resident tested positive for COVID-19 and was supposed to be under droplet precautions. However, there was no appropriate signage on the resident's door to indicate the need for specific PPE, and an Enhanced Barrier Precaution sign was incorrectly placed on the PPE cart. A CNA was unaware of the correct precautions and had to consult a Registered Nurse (RN), who then acknowledged the oversight and corrected the signage. The RN admitted that staff likely entered the resident's room without proper PPE from the time the resident tested positive until the signage was corrected, potentially exposing themselves to the virus.
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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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