Complete Care At Hales Corners
Inspection history, citations, penalties and survey trends for this long-term care facility in Hales Corners, Wisconsin.
- Location
- 9449 W. Forest Home Ave., Hales Corners, Wisconsin 53130
- CMS Provider Number
- 525596
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Complete Care At Hales Corners during CMS and state inspections, most recent first.
A resident with dementia and age-related osteoporosis, who had severe cognitive impairment, was observed receiving personal care from a CNA while undressed, with the room door and privacy curtains left open, making the resident visible from the hallway. The CNA later admitted not providing privacy and dignity, and both the RN supervisor and DON stated that staff are expected to ensure privacy and appropriate coverage during care. Facility admission documents state that residents are to be afforded dignity, respect, and privacy in treatment and care for personal needs.
The facility failed to conduct and document comprehensive investigations into allegations of neglect and abuse. In one case, a cognitively intact resident with cardiac and wound issues had a family member allege neglect after the resident was found with significant leg and foot swelling and was sent to the ED for acute CHF exacerbation; the facility’s investigation did not include interviews with other residents or staff education, despite policy requirements. In another case, a resident with vaginal cancer reported feeling intimidated when a CNA made a threatening remark after an accusation, yet the facility’s investigation did not include abuse-related education or further corrective action, and did not fully consider the CNA’s documented history of prior resident complaints about disrespectful communication, failure to follow resident preferences, and inadequate care setup.
A resident's legal representative, who held POA, requested copies of the resident's medical records but did not receive them due to staff oversight. The request form was completed and signed, but the Medical Records staff, relying on incorrect information, failed to process the request, resulting in the records not being provided as required by facility policy.
A resident with advanced dementia and a chronic facial mass developed a maggot infestation that was not consistently monitored or addressed in the care plan. Staff failed to investigate the cause of the infestation, did not document consistent interventions, and lacked a comprehensive plan to manage the maggots or the resident's refusals of care, resulting in a deficiency in providing care according to professional standards.
A resident with a left facial mass and multiple comorbidities was found with maggots and flies present on the wound, with nursing staff documenting ongoing issues of flies and maggots over several weeks. Despite the facility's pest control policy and regular general pest treatments in common areas, there was no evidence that pest control services were increased or that the resident's room was specifically treated for flies, and staff confirmed that exterminators were not directed to address flies in resident rooms.
Three residents with significant medical needs were transferred to the hospital on multiple occasions without receiving the required transfer and bed hold notices, including information on appeal rights and ombudsman contact details. This lapse occurred after the facility switched to a new EMR system, which did not automatically generate the necessary documentation, and staff did not provide the notices as required.
A resident with a history of dementia and prior ORIF surgery developed a wound that was not promptly or thoroughly assessed by clinical staff. The facility failed to document the wound's type and location, did not consult an orthopedic specialist when hardware was observed protruding, and lacked a care plan for pressure injury prevention prior to the wound's discovery. Physician assessments were incomplete, and oversight of the wound care program was unclear, resulting in delayed and insufficient evaluation and documentation.
Two residents did not receive necessary nutrition services: one experienced significant unaddressed weight loss without timely physician or dietician notification or care plan updates, and another, requiring supervision during meals due to severe cognitive impairment, was repeatedly left unsupervised while eating.
Staff did not follow established recipes when preparing pureed food, instead blending untoasted white bread with liquid cheese powder mix and relying on visual judgment for consistency. The food prepared for residents on pureed diets did not match the regular diet food, and available recipes were not used despite being accessible.
A resident with cognitive and physical impairments did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets, such as built-up utensils, a divided plate, and a nosey cup. Multiple observations showed that the required devices were often missing from the resident's meal trays, despite being documented as necessary and listed on tray tickets. Staff interviews confirmed inconsistencies in the process and a limited supply of certain adaptive items.
A resident with severe cognitive impairment reported being pushed by a CNA. The CNA was suspended and an investigation was conducted, including interviews and a body check that found no injuries. Despite facility policy requiring notification, law enforcement was not contacted regarding the abuse allegation.
The facility failed to provide appropriate pressure ulcer care and accurate documentation for two residents, leading to the deterioration of their wounds. The care plans were not updated, and the physician was not notified of changes in the wounds' presentation.
A resident reported a missing wallet containing money, credit cards, insurance cards, and a driver's license. The Social Worker interviewed the resident's family and staff but did not interview other residents to determine if they had any knowledge of the missing wallet or if they had any personal items missing. The Nursing Home Administrator was informed of the concern, but no further information was provided.
Failure to Provide Privacy and Dignity During Personal Care
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and privacy when a CNA provided personal care to one resident without closing the room door or drawing the privacy curtains. The resident, identified as R3, had been admitted with diagnoses including dementia and age-related osteoporosis, and had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. On 02/19/26 at 5:30 AM, observation from the hallway showed CNA1 at the resident’s bedside performing care while the resident was undressed, with the curtains and door open, making the resident visible from the hallway. During a subsequent interview at 5:37 AM, CNA1 acknowledged that she failed to provide privacy and dignity for the resident by not drawing the curtains and closing the door during care. At 5:40 AM, the nursing supervisor (RN3) stated that her expectation was that CNA1 should have provided privacy and dignity regardless of the time of day. Later, at 6:00 PM, the DON stated it was her expectation that CNA1 should have covered the resident during care. Review of the facility’s undated Admission Agreement showed that the facility committed to ensuring residents’ rights to dignified existence, respect, individuality, consideration, and privacy in treatment and care for personal needs, and to protecting and promoting each resident’s rights.
Failure to Conduct and Document Comprehensive Abuse/Neglect Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough investigation into an allegation of neglect for one resident and to fully evaluate a CNA’s history of concerning interactions with residents during an abuse/neglect investigation. One resident was admitted with diagnoses including myocardial infarction, congestive heart failure, and cellulitis. After a family member reported concern about swelling in the resident’s feet, nursing staff assessed the resident, noted bilateral leg and foot swelling, and recommended emergency room evaluation, after which the resident was admitted to the hospital for acute exacerbation of chronic heart failure. The family member later alleged neglect, and a grievance was filed with the assistance of the social worker. Despite this allegation and the resident’s documented cognitive intactness (BIMS score of 13/15), the facility’s investigation records did not show that other residents were interviewed about neglect concerns or that staff were educated on abuse and neglect policies as part of a comprehensive investigation. The Administrator stated she did not consider it necessary to interview other residents because she viewed the case as unique and without similar concerns among other residents, and she did not consider staff training necessary because she believed there was no actual neglect or abuse in this case. This approach was inconsistent with the facility’s written Abuse, Neglect and Exploitation policy, which requires immediate investigation procedures including identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation. A separate incident involved another resident with vaginal cancer who alleged that a CNA entered her room, came close to her, and stated, “Be sure you know who you accuse,” which the resident reported as intimidating. The facility’s investigation concluded the allegation was unsubstantiated and did not include documentation of abuse-related education or other training for the CNA or staff. Review of the CNA’s personnel file showed multiple prior resident complaints, including telling a resident to be more independent and not ensuring needs were met after providing supplies, using an authoritative tone, yelling at another resident for being wet, making embarrassing comments about incontinence, insisting on clothing choices against resident preference, repeating completed care tasks, and leaving a resident on the toilet long enough to play two games on her phone. Although the CNA had been placed on performance improvement plans for customer service, respectful communication, and resident rights, the Administrator reported she was unaware of all documented concerns and believed she could not use prior personnel records after a change in facility ownership. The facility’s investigation into the later abuse allegation did not reflect a review and integration of this history as part of a comprehensive investigation, contrary to the facility’s policy requiring complete and thorough documentation and focus on determining whether abuse, neglect, or mistreatment occurred.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's legal representative with access to or copies of the resident's medical records upon request. The resident, who had multiple complex diagnoses including fractures, heart disease, dementia, and other chronic conditions, was admitted to the facility and had a power of attorney (POA) designated as his daughter. The facility's policy required that, upon receiving a valid request for medical records, the requesting party should be notified of the cost and records should be made available after payment is received. The policy also specified that records should be gathered and secured once a request is made. Despite these procedures, the resident's daughter/POA submitted a completed and signed request form for the medical records. However, the Medical Records staff member failed to recognize that the form had been filled out and, based on incorrect information from the previous Nursing Home Administrator, believed the form was incomplete. As a result, the request was not processed, and the records were not provided to the resident's representative. This failure was confirmed during the survey when the completed form was found in an envelope, unprocessed, and the staff acknowledged the oversight.
Failure to Develop and Implement Care Plan for Maggot Infestation
Penalty
Summary
A resident with advanced dementia, chronic left facial mass (squamous cell carcinoma), and multiple comorbidities was observed to have a maggot infestation on the facial mass. The resident had a history of refusing treatment for the facial mass, which had been present and growing for at least two years. Despite the presence of a care plan for impaired skin integrity and infection risk, there was no specific care plan or consistent interventions documented for the management of maggots on the resident's facial mass. Nurses' notes and care plans did not consistently address the presence, monitoring, or treatment of maggots, and there was a lack of documentation regarding the number of maggots or the effectiveness of interventions. The facility failed to investigate the cause of the maggot infestation and did not develop or implement a comprehensive plan of care to address the infestation or the resident's refusals of care. Staff interviews revealed inconsistent awareness and documentation of the maggot issue, with some staff reporting direct observation of maggots and others denying any knowledge. The Director of Nursing and RN Supervisor were unable to provide evidence of an investigation into how the infestation occurred or how it was being managed, aside from sporadic notes and a brief incident report that lacked detailed follow-up or staff interviews. Throughout the period of infestation, there was no consistent monitoring or progress notes regarding the presence or removal of maggots, and interventions were sporadic and not clearly documented in the care plan. The lack of a specific maggot care plan, inconsistent monitoring, and absence of a thorough investigation into the infestation represent a failure to provide treatment and care in accordance with professional standards of practice and the resident's needs.
Failure to Address Fly Infestation in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in a resident with a left facial mass being found with maggot-like organisms on the mass. The resident, who had diagnoses including dementia, hypertension, depression, and squamous cell carcinoma of the skin, was observed on multiple occasions to have maggots and flies present on and around the facial wound. Nursing documentation described ongoing issues with maggots and flies, including observations of flies hovering around the resident and worms emerging from the wound. Despite these findings, there was no evidence that pest control services were increased or that the resident's room was specifically treated for flies during the period in question. Review of pest management inspection reports revealed that while general pest control treatments were conducted monthly in common facility areas, there was no documentation of targeted treatment for flies in the affected resident's room. Staff interviews confirmed the presence of flies in the room and indicated that the exterminator was not asked to address flies in resident rooms. The facility's pest control policy required a reporting system for issues arising between scheduled visits and treatment as indicated, but this was not implemented in response to the fly infestation in the resident's room.
Failure to Provide Required Transfer and Bed Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required transfer and bed hold notices to residents and/or their representatives during hospitalizations, as identified for three residents reviewed for hospitalization. Specifically, when residents were transferred to the hospital on multiple occasions, there was no documentation that the residents or their representatives received notices regarding the transfer, the reason for transfer, the location, appeal rights, or contact information for the State Long-Term Care Ombudsman. This deficiency was confirmed through interviews and record reviews, which showed that the facility had not been issuing these notices since switching to a new electronic medical record (EMR) system at the beginning of the year. The affected residents included individuals with significant medical conditions, such as a right leg fracture and chronic kidney disease, who experienced changes in condition necessitating hospitalization. Staff interviews revealed that the previous EMR system automatically generated the required notices, but the new system did not, resulting in a lapse in compliance. Despite some communication with families about bed hold options, there was no evidence that the formal transfer and bed hold notices were provided as required by facility policy and federal regulations.
Failure to Provide Timely and Comprehensive Wound Assessment and Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following the development of a wound. The resident, who had a history of dementia and an ankle fracture treated with open reduction and internal fixation (ORIF), was admitted to the facility and identified as being at risk for pressure ulcers. Despite this risk, there was no care plan in place for pressure injury prevention prior to the discovery of the wound. Upon identification of the wound, the facility did not document a comprehensive assessment to determine the wound type, nor did they specify the wound's location in initial evaluations. The facility's documentation was inconsistent and incomplete regarding the evaluation, assessment, treatment, and outcomes of the resident's wound. The wound was initially documented as an unstageable pressure injury without a clear location, and subsequent records failed to clarify whether the wound was pressure-related or associated with the resident's orthopedic hardware. There was also a lack of timely consultation with an orthopedic specialist when hardware was observed protruding from the resident's skin. Physician assessments did not include comprehensive wound evaluations or documentation of treatment progress, and the wound care plan was not updated until after the wound was discovered. Interviews with facility staff revealed that oversight of the wound care program was unclear, with responsibilities divided between the wound nurse, DON, and a newly hired nurse practitioner. The medical director acknowledged awareness of the hardware protrusion but did not provide documentation of a direct assessment. The wound nurse was unavailable for interview, and the facility was unable to provide evidence of timely or thorough physician evaluation of the wound. Ultimately, a nurse practitioner later determined the wound was related to the internal orthopedic device, not pressure, but this assessment occurred well after the initial deficiency in care and documentation.
Failure to Provide Adequate Nutrition and Supervision During Meals
Penalty
Summary
Two residents did not receive the necessary services to maintain acceptable nutrition and hydration. One resident with multiple diagnoses, including multiple sclerosis, atrial fibrillation, and dementia, experienced a 7.65% weight loss over approximately one month. This significant weight loss was not communicated to the physician or dietician, and there was no evidence of a comprehensive assessment or updated care plan to address the weight loss. The facility's policy required notification of the physician and dietician for significant weight changes, but this was not followed. Additionally, the resident was served food items not appropriate for their prescribed mechanical soft diet, and the correct dessert was not provided as indicated on the meal ticket. The dietary manager reported that weight monitoring was conducted monthly, and significant weight loss would be addressed at the next scheduled meeting. However, there was no documentation that the recent weight loss was addressed promptly or that interventions were implemented based on a comprehensive nutritional assessment. The facility's process for monitoring and responding to weight changes did not ensure timely communication or intervention for the resident's nutritional needs. Another resident with severe cognitive impairment and a care plan requiring supervision or touching assistance with eating was observed on two occasions eating unsupervised in their room. The resident's care plan and facility records indicated the need for supervision during meals, but staff did not provide the required assistance. The resident was left alone with their meal tray, and staff only entered the room briefly to assist with removing lids or to help with toileting, leaving the resident unsupervised for the majority of the meal.
Failure to Follow Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that food prepared for residents on a pureed diet was made according to established recipes designed to conserve nutritive value and flavor. During observation, Cook-C was seen preparing pureed grilled cheese by blending untoasted white bread with liquid cheese powder mix, without following a recipe. When questioned, Cook-C confirmed not using a recipe for pureed foods. The Food Service Manager (FSM)-D also stated that while recipes for pureed foods are available on the computer, they are not used, and the cook relies on visual judgment for consistency. FSM-D further clarified that the pureed food prepared did not match the regular diet food provided to other residents. The facility's policy on pureed food preparation requires that food be prepared to conserve nutritive value, flavor, and appearance, but does not specifically mandate the use of recipes. The recipe provided for pureed grilled cheese called for processing portions of grilled cheese sandwiches from the regular recipe and gradually adding hot milk, but did not specify the number of sandwiches to use. The surveyor found that the method observed did not align with the documented recipe or the food served to residents on a regular diet. No additional information was provided by facility leadership regarding the failure to follow recipes for pureed food.
Failure to Consistently Provide Required Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Parkinson's disease, osteoarthritis, osteoporosis, and unspecified lack of coordination did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets. The resident's care plan and occupational therapy notes indicated the need for built-up silverware, a divided plate, and a small nosey cup to support independent eating and drinking. Despite these documented needs, multiple observations by the surveyor revealed that the resident's meal trays frequently lacked one or more of the required adaptive devices, such as the divided plate and nosey cup, even though these items were listed on the tray tickets. Interviews with facility staff, including dietary aides, certified nursing assistants, and the food service director, confirmed that the process for ensuring adaptive equipment was collaborative, with occupational therapy communicating needs and dietary staff responsible for assembling trays accordingly. However, staff acknowledged inconsistencies in the provision of adaptive equipment, and it was noted that the facility had a limited supply of certain items, such as only one 4-ounce nosey cup, which was not always available for the resident. The surveyor's review of the facility's policy on meal supervision and assistance further highlighted the expectation that trays be checked for correct diet, food consistency, and necessary adaptive devices before serving. Despite this policy, the resident did not consistently receive the adaptive equipment required for independent eating, as evidenced by repeated mismatches between the meal tray tickets and the items actually provided on the trays.
Failure to Notify Law Enforcement of Alleged Abuse
Penalty
Summary
The facility failed to notify law enforcement regarding an allegation of abuse involving a resident with severe cognitive impairment. On 4/20/25, a resident with diagnoses including dementia, chronic kidney disease stage 3, and spinal stenosis reported to an RN Supervisor that a CNA had pushed her. The CNA was immediately suspended pending investigation, and a body check revealed no injuries or discoloration. The facility's investigation included interviews with staff and other residents, and the resident was reinterviewed the following day but did not recall the incident. Despite the facility's policy requiring notification of law enforcement for all alleged violations involving abuse, the investigation documentation did not indicate that law enforcement was notified. The Nursing Home Administrator confirmed to the surveyor that police were not contacted because no injuries were observed on the resident. No further explanation was provided for the failure to report the allegation to law enforcement as required by facility policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice. Specifically, two residents, R43 and R19, were identified as not receiving appropriate pressure ulcer care. R43 was admitted with multiple pressure injuries, including an unstageable pressure injury to the right elbow, which worsened over time. The documentation for R43's wounds was inconsistent and lacked accurate descriptions of staging, measurements, and characteristics. Additionally, the care plan did not adequately address offloading or decreasing pressure on the elbow, leading to further deterioration of the wound. R43 also developed new pressure injuries to the left heel and right Achilles, which were not properly documented or managed according to the facility's policy and procedure for pressure ulcer management. The facility failed to notify the physician of changes in the wound's presentation and did not stage the wound accurately when the base was visible. The care plan was not updated to include recommendations from the wound clinic, and there were inconsistencies in the documentation of the left heel and right Achilles wounds. R43 was eventually transferred to the hospital for cardiac concerns and did not return to the facility during the survey. R19 was admitted with a Stage 3 pressure injury to the right outer ankle, which was not properly managed or documented. The wound did not show significant improvement, and the treatment orders remained unchanged despite the wound's deterioration. The facility failed to notify the physician of changes in the wound's presentation, and the documentation was inconsistent and inaccurate. The hospice RN involved in R19's care did not take measurements of the wound, relying on the facility's documentation, which was found to be inaccurate. The facility's failure to provide appropriate pressure ulcer care and accurate documentation led to the deficiency identified in the survey.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility did not thoroughly investigate an allegation of misappropriation affecting a resident who reported a missing wallet. The wallet contained money, credit cards, insurance cards, and a driver's license. The Social Worker (SW) initiated an investigation by interviewing the resident's family members and staff who worked during the period when the wallet was last seen. However, the SW did not interview any other residents to determine if they had any knowledge of the missing wallet or if they had any personal items missing, which could have broadened the scope of the investigation. The SW acknowledged that they had overheard the resident discussing the missing wallet with other residents, but no further steps were taken to interview those residents. The Nursing Home Administrator (NHA) was informed of the concern that no other residents were interviewed to determine if the incident was isolated or if there was any additional information that could help discover what happened to the wallet. The NHA did not provide any further information at that time.
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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