Chippewa Manor Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Chippewa Falls, Wisconsin.
- Location
- 222 Chapman Rd, Chippewa Falls, Wisconsin 54729
- CMS Provider Number
- 525419
- Inspections on file
- 13
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Chippewa Manor Nursing And Rehabilitation during CMS and state inspections, most recent first.
Failure to Provide Consistent PI Care and Skin Monitoring: The facility did not consistently prevent or treat pressure injuries for three residents. One resident at very high risk did not receive timely heel offloading or weekly comprehensive PI measurements, another had heel wounds that were not staged and lacked consistent assessment documentation, and a third had recurrent skin breakdown without current treatment orders, weekly comprehensive skin assessments, or documented provider notification. Staff and DON/ADON interviews confirmed gaps in assessment, staging, and individualized interventions.
Failure to transmit a resident’s death MDS assessment to CMS occurred after the RN/MDS coordinator completed the assessment but did not hit the complete button. The DON and ADON stated only three staff had access to transmit MDS assessments, and they were not aware the assessment needed transmission because it was not completed in the system.
A resident with ESRD and dementia did not receive ongoing assessment and monitoring related to dialysis treatments. Staff documented vital signs and post-dialysis bruit checks, but there were no pre- and post-dialysis weights and no documented communication with the dialysis center. The RN and DON confirmed the facility lacked clear documentation of dialysis-related communication and oversight for the resident’s treatments.
A facility failed to maintain proper infection control when a laundry aide did not sanitize hands between delivering clean linens to residents and left the linen cart uncovered, risking contamination. The Director of Nursing confirmed the expectation for covered carts and hand hygiene, which the aide acknowledged forgetting.
A facility failed to provide written notification of a resident's transfer to the resident's representative and the Ombudsman. The resident, with conditions including metabolic encephalopathy and end-stage renal disease, was hospitalized for behavioral issues and returned to the facility after dialysis. The DON confirmed that no written notice of the transfer was completed or sent.
A facility failed to notify a resident's representative in writing about the bed hold policy upon the resident's transfer to a hospital. The resident, with conditions including metabolic encephalopathy and end-stage renal disease, was hospitalized for urgent dialysis needs. Although the facility provides a Client Handbook with bed hold policy information upon admission, no specific notification was given at the time of transfer.
The facility failed to securely store controlled medications for two residents, as observed during a survey. Two bottles of Lorazepam were found in a refrigerator without being double-locked, despite repeated recommendations from the contracted pharmacy. The ADON acknowledged that one bottle should have been discarded as the resident had been discharged. The DON confirmed the oversight in implementing the pharmacy's recommendations.
Failure to Provide Consistent Pressure Injury Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for three residents reviewed for pressure injuries. The report states that R48 and R47 were cited at actual harm/isolated, and R51 was cited at potential for minimal harm/isolated. The facility also did not complete comprehensive weekly skin assessments with staging, did not obtain physician orders for wound treatments in one case, and did not consistently implement interventions to promote skin integrity and healing. R48 was admitted with diagnoses including hospice/palliative care, Alzheimer’s disease, congestive heart failure, and legal blindness, and was dependent on staff for all ADLs. A Braden score of 9 placed R48 at very high risk for pressure injury development. The record showed a red area to the lower spine on 03/01/26, but the facility did not have weekly assessment measurements of the heel, and the hospice RN was expected to document the pressure injuries. The ADON stated the facility typically would have hospice assess and enter orders to document the pressure injuries three times a week, but this was not done. The DON stated the facility did not complete weekly comprehensive PI assessments and staging. Interventions such as heel floating and an air mattress were not added until after the pressure injuries developed. R47 was admitted with diagnoses including hospice/palliative care, metastatic cancer, tumor lysis syndrome, depression, and chronic kidney disease. The admission MDS documented a BIMS of 15/15 and a Braden score of 17, indicating mild risk. The admission observation report documented no pressure injuries and only a scab on a toe, yet later documentation showed an unstageable left heel pressure ulcer and a right heel wound. Physician orders included heel floating or heel protectors and wound care with measurement and documentation, but the facility did not stage the pressure injuries in the progress notes. The wound management detail report created by the ADON stated the left heel ulcer was observed on 02/25/26, while the ADON and DON told the surveyor the area was present on admission; however, the ADON also stated she did not see the wound on admission and the DON stated she observed it but did not take measurements or document the assessment. The facility did not add heel-floating interventions to the care plan until 03/02/26, and there was no comprehensive assessment for the right heel during the week of 03/03/26. R51 had diagnoses including dementia, dialysis dependence, heart failure, and obesity, and the MDS noted risk for pressure ulcers. The resident had a history of recurrent skin breakdown, including buttock wounds documented in multiple progress notes, but the record did not contain weekly comprehensive skin assessments or current physician orders for skin treatment. The only treatment order found was from 11/25/25 to 01/01/26 for a right buttock wound; no current skin treatment orders were located, and no orders for wound-healing supplements were present. After hospitalization for urosepsis and readmission, the skin assessment documented shearing-type areas on both thighs, but no further skin assessments or progress notes were found after that date. During observation, the surveyor saw an open area on the left inner buttock and dark purple discoloration on the right buttock, while the RN stated the resident sat a lot and was unsure whether there was an order for treatment or who had placed the dressing. The DON and ADON stated the wounds heal and reoccur, but they did not provide documentation of provider notification, individualized interventions, or weekly comprehensive skin assessments.
Failure to Transmit Death MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for one resident who expired in the facility with hospice services was transmitted to the CMS system within 14 days of completion. The resident’s death MDS assessment was completed by the RN who also served as the MDS coordinator, but it was not submitted. Surveyor review found that the facility did not provide its policy related to MDS assessments when requested. During interview, the RN stated she completed the resident’s MDS, while the DON and ADON were responsible for transmitting it. The DON and ADON stated that the MDS coordinator is supposed to hit the complete button when finished, after which it is sent to the NHA, DON, and/or ADON for transmission. The DON also stated that only three staff members had access to transmit MDS assessments and that because the MDS coordinator did not hit complete, the NHA, DON, and ADON were not aware the resident’s MDS needed to be transmitted.
Failure to Monitor Dialysis Resident Before and After Treatments
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one resident who required dialysis. The facility did not ensure ongoing assessment of the resident’s condition and monitoring for complications before and after dialysis treatments. The resident had diagnoses including dementia and end stage renal disease with dependence on dialysis, and the MDS showed moderate cognitive impairment with a BIMS score of 11/15. The care plan identified the resident’s need for dialysis-related monitoring, including weights before and after dialysis, assessment for swelling and shortness of breath, lab monitoring, and communication with the dialysis facility. Record review showed the resident had orders for dialysis on Monday, Wednesday, and Friday, check and document bruit and thrill of the left forearm fistula, provide supper upon return from dialysis, and monitor vital signs three times per week post dialysis. Survey review found vital signs, temperature, respirations, and blood pressure documented pre and post dialysis, but no pre- and post-dialysis weights and no communication with the dialysis center. Staff interviews confirmed nurses were responsible for vital signs and post-dialysis assessment, but the RN did not know where communication with the dialysis center would be located, and the DON stated there was no documented communication with the new dialysis center related to the resident’s dialysis treatments.
Infection Control Lapse in Linen Delivery
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, impacting five residents. The deficiency was observed when a laundry aide (LA) did not sanitize their hands between delivering clean linens to residents and failed to cover the clean linen cart, leaving it exposed to potential contamination. The LA was seen carrying residents' clothes to the first floor and placing them in dressers and closets without sanitizing hands between rooms. This included entering a room with Enhanced Barrier Precautions (EBP) without following proper hand hygiene protocols. The Director of Nursing (DON) confirmed that the expectation is for the clean linen cart to be covered at all times to prevent contamination and for staff to sanitize their hands in and out of all resident rooms. The LA acknowledged forgetting to cover the cart and admitted that hands should be sanitized between rooms, especially when handling items in an EBP room. This oversight in infection control practices was identified during a survey, highlighting a lapse in adherence to the facility's infection prevention policies.
Failure to Notify Resident's Representative and Ombudsman of Transfer
Penalty
Summary
The facility failed to provide timely written notification of a resident's transfer to the resident's representative and the Ombudsman. This deficiency was identified during an investigation of a resident who was admitted with diagnoses including metabolic encephalopathy, end-stage renal disease, and dependence on renal dialysis. The resident was hospitalized for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. Although the resident was dialyzed and improved, returning to the facility the following day, the facility did not issue a written notice of the transfer to the resident's representative or the Ombudsman. The Director of Nursing confirmed that no written transfer notice was completed or sent.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing about the bed hold policy upon the resident's transfer to a hospital. The resident, who was admitted to the facility with diagnoses including metabolic encephalopathy, end-stage renal disease, and dependence on renal dialysis, was hospitalized for increased agitation, confusion, threats to self, behavior changes, and elopement attempts. The resident was dialyzed and improved, returning to the facility the following day. However, the facility did not provide documentation that the resident's representative was informed of the bed hold policy upon the resident's transfer or within 24 hours of the transfer, as required. The surveyor noted that the facility's Client Handbook, which includes bed hold policy information, is given to residents upon admission, but no specific notification was provided at the time of the transfer.
Failure to Securely Store Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were securely stored, specifically for two residents, R2 and R246. During a survey on January 27, 2025, it was observed that two bottles of Lorazepam 2mg/ml, one for each resident, were stored in a refrigerator in the medication storage room without being double-locked, as required for controlled substances. The Lorazepam bottle for R2 had been opened on December 16, 2024, and the one for R246 on January 1, 2025. The Assistant Director of Nursing (ADON) acknowledged that the Lorazepam bottle for R2 should have been discarded since the resident had been discharged. The surveyor reviewed the facility's medication storage review sheets from the contracted pharmacy, which had repeatedly recommended that Lorazepam concentrate be double-locked in audits conducted from August to November 2024. Despite these recommendations, the facility did not implement the necessary security measures. The Director of Nursing (DON) confirmed that all controlled medications should be double-locked and acknowledged the oversight in monitoring and implementing the pharmacy's recommendations.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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