Complete Care At Nazareth Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Stoughton, Wisconsin.
- Location
- 814 Jackson St., Stoughton, Wisconsin 53589
- CMS Provider Number
- 525681
- Inspections on file
- 25
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Complete Care At Nazareth Llc during CMS and state inspections, most recent first.
Meals were not served at the posted times or in line with resident preferences. Surveyors observed lunch and breakfast being delayed well past scheduled times, and residents reported that meals were routinely late, dinner was often served after 6:00 PM, and food was cold by the time it reached them. The NHA acknowledged the lateness had been excessive.
Food service safety standards were not followed when the kitchen’s 3-compartment sink sanitizer tested at 0 PPM instead of the manufacturer’s required range, and the Dietary Manager reported the sink could not reach the needed sanitization level. Surveyors also found thawed nutritional shakes, nutritional juices, and grilled cheese sandwiches in storage with no thaw dates or dates, including items in the kitchen refrigerator and a med room refrigerator.
Garbage and refuse were observed on the ground near and under the facility’s main dumpsters, including egg crates, tissue boxes, plastic utensils, cardboard boxes, condiment packets, a coffee bag, used garbage bags, and surgical masks. A Cook stated the area was gross, and the DM later stated the dumpster area is cleaned regularly.
The facility’s IPC program was deficient because staff illness surveillance records were incomplete, with vague symptom entries and missing onset, end, and last-worked dates for multiple staff with GI symptoms. In addition, a resident on contact precautions for emesis and bloody mucous stool was observed when a CNA entered the room without gown, gloves, or hand hygiene, picked up a used tissue with bare hands, and exited without hand hygiene, despite staff and DON expectations that PPE and hand hygiene be used every time the room is entered.
Meal ID tickets and dietary instructions were not followed for multiple residents during meal service. A resident with severe cognitive impairment was served ground meat without the required gravy, another resident with Alzheimer’s disease and dysphagia received oatmeal instead of the cold cereal listed on the ticket, and a resident with diabetes and dysphagia was served oatmeal even though it was listed as a dislike. Another resident with hemiplegia/hemiparesis and diabetes did not receive extra gravy/sauce or fruit as directed on the meal ticket, and staff acknowledged that the kitchen often mixed up food items and that residents should not receive disliked foods.
Food Not Palatable at Meals: Multiple residents reported that the pork chop served at lunch was hard, dry, and difficult or impossible to eat. Two cognitively intact residents and two residents with moderate cognitive impairment all voiced concerns, and a surveyor’s test tray confirmed the pork chop was very hard and dry. The DM stated the pork chop may have been prepared, frozen, and then re-cooked.
An LPN administered metoprolol to a resident who did not have an order for it; the medication belonged to the resident's roommate. Surveyor observation and MAR review confirmed the wrong-drug, wrong-resident error, and the DON identified it as a significant medication error. The resident had vascular dementia and severe cognitive impairment.
Expired medications were found in the Main Medication Stock Room, including multiple bottles of Mylanta, Melatonin, Aspirin, multivitamins, and vitamin B12. An LPN confirmed the medications were expired and said they should not have been in stock, and the DON stated expired meds should not be in the medication rotation.
Failure to Follow Fall Interventions for a Resident in a Broda Chair: A resident with severe cognitive impairment, a fractured hip history, and repeated falls from a Broda chair had care plan interventions to recline the chair when unattended and remove the Hoyer sling after transfers. Surveyors repeatedly observed the sling left under the resident while she sat in the Broda chair, and CNA staff were unable to identify the resident’s fall interventions. The DON confirmed the resident had multiple falls from the chair and that staff were not consistently following the care planned interventions.
A resident with mobility impairments and multiple medical conditions requested a new wheelchair for use outside the facility, but experienced significant delays due to lack of timely follow-up and documentation by social services. Despite therapy recommendations and repeated requests, the referral process was not completed in a timely manner, and communication with the equipment vendor was insufficient, resulting in the resident continuing to use an unsuitable wheelchair.
The facility failed to provide residents with food and drink at safe and appetizing temperatures, as multiple residents reported dissatisfaction with meal temperatures. Observations confirmed that hot foods were served cold and cold foods were served warm, contrary to the facility's policy. The Food and Service Director and District Manager acknowledged the concerns, indicating a systemic issue with food service practices.
The facility did not maintain a sanitary environment for food handling, as observed when the Food Service Director used the same gloves to touch various items and food without washing hands or changing gloves. This was against the facility's policy, which requires handwashing and glove changes to prevent contamination.
The facility failed to provide necessary treatment for pressure injuries, as evidenced by incomplete documentation for a resident's wound care and another resident's wound being left uncovered for two hours. Staff interviews revealed that treatments were not consistently documented or completed as ordered, and wounds were not promptly covered after showers, contrary to standard practices.
A resident with parkinsonism and dysphagia was observed eating alone despite needing supervision per their care plan. The resident struggled with the meal, which was not suitable for their condition. Staff interviews confirmed the need for supervision, and facility leadership acknowledged the expectation to follow the care plan.
A facility failed to provide proper pharmaceutical services, leading to medication errors for two residents. One resident received incorrect pain medication due to transcription errors and an inaccurate narcotic count. Another resident's medication was improperly prepared using a contaminated pill cutter. The Director of Nursing acknowledged these issues during a survey.
A facility was found to have deficiencies in its infection control program during wound care procedures. An RN was observed touching surfaces with dirty gloves and failing to perform hand hygiene before handling a resident's belongings. In another instance, the RN did not secure a garbage bag, leading to soiled dressings falling on the floor, and continued to handle items without changing gloves. The DON confirmed that infection control practices were not followed correctly.
A resident with severe cognitive impairment eloped from a facility due to inadequate supervision and malfunctioning door alarms, resulting in a fall and a fractured jaw. The facility's failure to implement its elopement policy and monitor alarm systems contributed to the incident, with other residents also at risk due to similar deficiencies.
Meals Served Late and Not Consistent With Posted Schedule
Penalty
Summary
Meals were not served at the scheduled times in accordance with residents’ needs, preferences, and requests. The facility’s policy stated that each resident would receive at least three meals daily without extensive time lapses between meals, and the facility’s posted meal schedule listed regular breakfast, lunch, and dinner times for each dining room. However, surveyor observations showed lunch on the 2nd floor did not begin until 12:23 PM instead of 11:40 AM, and lunch on the 1st floor did not begin until 12:55 PM instead of 11:50 AM. Surveyor also observed lunch trays being delivered in the 1st floor hallways at 12:54 PM. Resident interviews and council comments confirmed that the late meal service was ongoing. R2 stated lunch was really late, R3 stated meals are always late, and during resident council R2, R3, and R19 said meals were a big problem and that the facility knew about it but nothing was being done. R3 stated dinner was usually served well after 6:00 PM and that meals were served more often late than on time, while R19 stated meals were always late and were cold by the time they were served. The surveyor also observed breakfast trays being delivered on the 1st floor at 8:42 AM, and the NHA agreed the lateness of meals that week had been excessive.
Food Safety and Dating Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. In the main kitchen, the three-compartment sink used for washing larger pots, pans, and utensils had a sanitizing solution that did not meet the manufacturer’s required parts per million level. Surveyor observation showed the sink basin contained a large pile of apparently clean dishes, and the sanitizing water measured 115 degrees Fahrenheit. When the solution was later tested at 77 degrees Fahrenheit using the manufacturer-recommended test strips, the strip did not change color, indicating a PPM of 0. The Dietary Manager stated she had been testing the sink the prior night, could not get it to reach the necessary sanitization level, and had temporarily taken the sink out of commission while contacting the manufacturer for assistance. The facility also had food items in storage that were improperly dated or not dated. In the main kitchen refrigerator, surveyor observed thawed vanilla nutritional shakes, thawed chocolate nutritional shakes, and two grilled cheese sandwiches wrapped in foil with no dates. In the second-floor medication room refrigerator, surveyor observed eight frozen nutritional juices with no thaw dates. The nutritional juices and shakes used by the facility are stored frozen and the packaging states they must be used or discarded within 14 days of thawing. The Dietary Manager stated that shakes or nutritional juices that are thawed and not dated need to be discarded because there is no way of knowing when they were removed from the freezer.
Improper Disposal of Garbage and Refuse Near Dumpsters
Penalty
Summary
Garbage and refuse were not disposed of properly in the area around the facility's main dumpsters. On 3/30/26 at 8:46 AM, the surveyor and CK J, a Cook, observed garbage and refuse on the ground near and under the dumpsters, including 2 empty egg crates, empty tissue boxes, plastic forks, spoons, and knives, cardboard boxes, various sauce and condiment packets, an empty plastic bag of coffee, empty used garbage bags that appeared tied and discolored, and surgical masks. CK J stated at that time that the area was gross. On 4/2/26 at 10:49 AM, DM K, the Dietary Manager, stated that cleaning the dumpster area is completed regularly but would ensure consistent proper disposal and cleaning is carried out.
Infection Control Program and Contact Precaution Failures
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility’s employee surveillance list for staff illness was incomplete. It included vague symptom descriptions such as “sick,” “sick-stomach,” and “not feeling well,” and it did not consistently document onset dates, end dates, or last day worked. The line list showed multiple staff members with gastrointestinal symptoms, including vomiting and diarrhea, but several entries lacked end dates, return-to-work dates, or last day worked information. During interview, the Infection Preventionist/ADON stated that when a staff member calls in with GI symptoms, she determines return-to-work based on when symptoms end and then waits 48 hours after symptoms stop, or 72 hours for kitchen staff. She also stated that she used the new spreadsheet with HR but did not always write down the end date, and acknowledged that without an end date she could not determine a return-to-work date from the spreadsheet. The DON stated that the spreadsheet for staff infection surveillance should be filled out completely in order to track infections. The facility policy stated that employees restricted from work shall remain away until no longer contagious or cleared by a medical professional as needed. The facility also failed to follow contact precaution protocol for a resident who had emesis and bloody mucous stool and was placed on contact isolation with full PPE ordered. The resident’s chart documented contact precautions for loose stool/emesis, and the care plan noted the gastrointestinal alteration. On observation, a CNA entered the resident’s room without gown, gloves, or hand hygiene, picked up a used tissue from the floor with bare hands, placed it in the garbage can inside the room, and exited without performing hand hygiene. The CNA stated she had been told the resident was off contact precautions that day, while multiple other staff members and the DON confirmed that gowns and gloves were expected every time the room was entered and that hand hygiene was required.
Meal ID Tickets and Dietary Instructions Not Followed
Penalty
Summary
The facility did not ensure that meal identification tickets and dietary instructions were followed for multiple residents during meal service. Survey observation and record review showed that R54, who had orders for a consistent carbohydrate diet, mechanical soft texture, thin liquids, and gravy to all ground meat, was served ground meat without gravy at breakfast. R54 also had severe cognitive impairment with a BIMS score of 3. When the surveyor asked CNA H about the meal ticket and the missing gravy, CNA H confirmed that gravy should have been on the ground meat. The facility also did not follow meal ticket instructions for R34 and R24 at breakfast. R34, who had diagnoses including Alzheimer’s disease and dysphagia and was ordered a regular diet with mechanical soft texture and nectar-thick liquids, was observed receiving oatmeal even though the meal ticket indicated cold cereal. R24, who had diagnoses including type 2 diabetes mellitus and dysphagia and was ordered a consistent carbohydrate diet with regular texture and thin liquids, had a meal ticket listing oatmeal as a dislike and cold cereal as the served item, yet was observed receiving oatmeal. R24 stated she did not like oatmeal and would rather have cold cereal. CNA H acknowledged that the kitchen staff often mixed up cold cereal and oatmeal and that residents should not receive disliked foods. The deficiency also involved R32, whose meal ticket instructed staff to provide extra gravy/sauce and offer fruit because he disliked vegetables. R32, who had hemiplegia/hemiparesis and type II diabetes mellitus and had a BIMS score of 11/15, was observed at lunch with no extra gravy for his pork chop, vegetables on his plate, and no fruit provided. R32 stated he could not eat the meal without gravy and did not like vegetables. The DON and dietary manager both acknowledged that diet staff were expected to follow diet orders, menus, and meal ID tickets, and that disliked foods should not be served as listed on the ticket.
Food Not Palatable at Meals
Penalty
Summary
The facility did not ensure that each resident received food that was palatable. During observation, interview, and record review, residents R5, R25, R32, and R55 all voiced concerns that their meals were not palatable, with the pork chop specifically described as hard, dry, and difficult or impossible to eat. R5, who had a BIMS of 14/15 and was cognitively intact, stated that lunch was terrible and that the pork chop was hard and could not even be eaten. R25, who had a BIMS of 15/15 and was also cognitively intact, was observed eating a peanut butter and jelly sandwich while a full meal sat in front of her; she stated that she could not eat the meal because the pork chop was too tough to cut through. R32, whose MDS showed a BIMS of 11/15 with moderate impairment but who understood and was understood by others, was observed at the lunch table and stated he was supposed to receive extra gravy but did not get it, and that he would not be able to eat the pork chop because it was too hard. R55, whose BIMS was 9/15 with moderate impairment but who was able to ask and answer questions with good understanding, demonstrated with his fork that he could not eat the pork chop. A surveyor also received a test tray from the kitchen and found the featured pork chop to be very hard and dry, difficult to chew, and unable to be swallowed. The Dietary Manager stated that the pork chop may have been prepared, then frozen, and then re-cooked.
Significant Medication Error: Wrong Resident Received Metoprolol
Penalty
Summary
A significant medication error occurred when an LPN administered metoprolol succinate extended release 50 mg to R61 even though R61 did not have an order for metoprolol. Surveyor observation showed the medication was given to R61 during the medication administration task, and later record review confirmed that R61's physician orders did not include metoprolol. The facility's medication administration policy required staff to follow the six rights of medication administration and compare the medication source with the MAR to verify the right resident and right drug. R61 was admitted with diagnoses including vascular dementia, hemiplegia, and hemiparesis, and the Quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment. R61's March MAR listed morning medications including aspirin, furosemide, Miralax, vitamin D3, metformin, senna-docusate, and acetaminophen, but not metoprolol. The DON reviewed the MARs and confirmed that R61's roommate had an order for metoprolol, and stated that the LPN had administered the roommate's metoprolol to R61, identifying it as a significant medication error.
Expired Medications Found in Stock Room
Penalty
Summary
The facility did not ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. During a medication storage observation in the Main Medication Stock Room, surveyors found multiple expired medications, including six bottles of Mylanta Antacid Liquid, three bottles of Melatonin 1 mg tablets, one bottle of Aspirin 325 mg tablets, three bottles of multivitamin tablets, and one bottle of vitamin B12 100 microgram tablets. The expired Mylanta bottles had expiration dates of 11/25, 11/24, and 5/25, and the other expired medications had expiration dates of 8/25, 1/26, 2/26, and 11/25. During interview, an LPN confirmed that the Mylanta bottles and the other medications were expired and stated they should not have been in the stock medication room. The LPN said the expired bottles would be removed and destroyed. The DON also stated that expired medications should not be in the stock medication rotation and that staff were expected to check expiration dates when taking medications from the stockroom and placing them in medication carts.
Failure to Follow Fall Interventions for a Resident in a Broda Chair
Penalty
Summary
The facility failed to ensure adequate interventions were in place to keep a resident safe from accidents and prevent further falls. The resident had severe cognitive impairment with a BIMS score of 00 out of 15, a history of a fractured hip, and was dependent on a Broda chair for transportation with Hoyer lift transfers requiring 2 staff. Her care plan identified her as at risk for falls and included interventions to follow the facility fall protocol, recline the Broda chair when unattended, and remove the Hoyer sling when she was up in the Broda chair. The resident had three documented falls from or out of her Broda chair. After the first fall, she was found on the floor after sliding out of the chair. After the second fall, she was found sitting on the floor next to her Broda chair after hospice staff had given her a shower and left her in the chair in her room. The interdisciplinary team noted that she would benefit from reclining the Broda chair back when unattended. After the third fall, staff witnessed her slowly slide out of the Broda chair while they were caring for her roommate, and the interdisciplinary team noted that she would benefit from staff removing the Hoyer sling when she was up in the Broda chair. Surveyors observed the resident multiple times with a Hoyer sling left under her while she was seated in the Broda chair in the dining room. During these observations, she appeared restless and repeatedly shifted forward and backward and slouched down in the chair. When interviewed, CNA staff were unable to state what fall interventions were in place or where to find them, and an LPN stated that staff try not to leave her in the Broda chair by herself. The DON stated that the resident had three falls, two within the last month, and that the intervention after the most recent fall was to remove the Hoyer sling after transfers and keep it out from underneath her. The report states the facility failed to ensure that fall interventions were being followed for the resident.
Failure to Provide Timely Medically-Related Social Services for Wheelchair Acquisition
Penalty
Summary
A deficiency occurred when the facility failed to provide medically-related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being. The resident, who was cognitively intact and had diagnoses including Parkinsonism, gait and mobility abnormalities, low back pain, weakness, and depression, requested a referral for a new wheelchair suitable for use outside the facility. The resident reported that the current wheelchair did not fold and was unsuitable for outings, resulting in the use of an ill-fitting borrowed chair when leaving the building. Despite approval from Occupational Therapy and multiple letters of recommendation, the resident experienced significant delays in obtaining a new wheelchair. The process for obtaining the new wheelchair involved several steps, including a therapy recommendation, physician order, and submission of paperwork to a DME vendor. Documentation and interviews revealed that the initial referral was either not received or not processed by the vendor, and there was a lack of timely follow-up from the facility's Social Services Director. The Social Services Director stated that the referral was faxed and refaxed to the vendor, but the vendor had no record of receiving it prior to a later date. There was also no documentation of follow-up communication attempts or updates provided to the resident or their representative during the period of delay. Interviews with facility staff, the vendor, and the resident's representative confirmed that communication breakdowns and lack of documentation contributed to the delay in securing the appropriate wheelchair. The facility did not have a policy for requisition of wheelchairs available for review, and the Social Services Director acknowledged that updates to the resident were only given in passing and not documented. The Nursing Home Administrator agreed that referrals should be sent promptly, followed up on, and documented, but this did not occur in this case.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable and at safe and appetizing temperatures. Multiple residents expressed concerns about the temperature and quality of the food, with hot foods being served cold and cold foods being served warm. Observations and interviews with residents revealed consistent dissatisfaction with meal temperatures, and test trays confirmed that food items were not served at desirable temperatures. For instance, scrambled eggs, bacon, and oatmeal were served at temperatures significantly below the facility's policy requirements, and beverages like milk and juice were served warmer than expected. Residents reported that the food was often not palatable, with some describing it as lukewarm or cold. Specific examples included a resident who noted that the french fries were always cold and undercooked, and another who mentioned that the soup was only a little warm. The facility's Food and Service Director and District Manager acknowledged the concerns raised by residents and the surveyor's findings. Despite the facility's policy requiring hot foods to be served at a minimum of 135°F, the observed temperatures were consistently below this standard, indicating a systemic issue with food service practices.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 65 residents. During an observation, the Food Service Director (FSD) was seen taking temperatures of lunch items while wearing gloves. The FSD touched various items, including a thermometer, alcohol wipes, a hot pad, and lids on pans, before directly handling chicken with the same pair of gloves. The FSD then proceeded to the dishwashing room, used a cell phone, and touched the steam table without changing gloves or washing hands. The facility's policy on General Food Preparation and Handling, dated 2023, specifies that bare hands should not touch ready-to-eat raw food directly, and disposable gloves are to be discarded after each use. Employees are required to wash their hands before putting on gloves and after removing them. On a subsequent interview, both the Food Service Director and the District Manager acknowledged that they would expect staff to change gloves and wash hands before and after directly touching food items. The failure to adhere to these standards resulted in the deficiency noted by the surveyor.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. For one resident, identified as R34, there were multiple instances in October and December where wound care treatments were not documented as completed. Despite the lack of documentation, R34's wounds did not cause more pain or become infected. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that a blank in the Treatment Administration Record (TAR) could indicate that the treatment was not completed, as treatments should be signed out and completed as ordered. Another resident, identified as R51, had a pressure injury that was left open to air for approximately two hours after a shower, contrary to the standard practice of not leaving a wound uncovered for more than 30 minutes. The RN responsible for R51's care acknowledged that the dressing should have been applied immediately after the shower. The DON confirmed that wounds should not be left uncovered and that the dressing should have been applied without delay. These deficiencies highlight lapses in the facility's wound care practices, potentially impacting the healing process of the residents' pressure injuries.
Inadequate Supervision During Meals for Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident identified as R11. R11's care plan required supervision during meals due to medical conditions including parkinsonism, dysphagia, and mild cognitive impairment. Despite this, the surveyor observed R11 eating alone in his room, struggling with the meal, which was spaghetti, a food item R11 had difficulty eating. R11 expressed difficulty with the meal and noted that the food was delivered cold. Interviews with facility staff, including a Registered Nurse and a Speech Therapist, confirmed that R11 required supervision during meals as per the care plan. The Nursing Home Administrator and Director of Nursing acknowledged the expectation for staff to follow the care plan, including supervision and preferred food items. The facility's failure to adhere to the care plan resulted in inadequate supervision for R11, as evidenced by the observations and staff interviews.
Medication Errors and Contaminated Equipment in LTC Facility
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, resulting in medication errors affecting two residents. Resident R38 received the wrong pain medication on two consecutive days, and there was an inaccurate narcotic count for this resident. The errors were due to incorrect transcription of medication orders and the use of the wrong medication card, leading to discrepancies in the controlled drug record. Despite these issues, the Director of Nursing initially stated there were no medication errors for R38. Additionally, RN G used a contaminated pill cutter to cut an unscored tablet for Resident R50. The pill cutter contained residue from previously cut medications, which was not cleaned before use. RN G acknowledged the mistake, indicating that only scored tablets should be cut and that the pill cutter should have been cleaned prior to use. The Director of Nursing confirmed that the pill cutter should be clean and that unscored tablets should not be cut. These deficiencies highlight a lack of adherence to the facility's medication administration policies, which require following the six rights of medication administration and ensuring medications are administered according to physician orders and manufacturer specifications. The errors were identified during a survey, and the facility's Director of Nursing acknowledged the issues when interviewed by the surveyor.
Infection Control Deficiencies During Wound Care
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, as evidenced by the actions of RN F during wound care procedures. During an observation, RN F was seen performing wound care for a resident with a pressure injury without adhering to standard infection control practices. Specifically, RN F touched the bed side table and bed controller with dirty gloves after removing a used dressing, and only then removed the gloves and performed hand hygiene. This was acknowledged by RN F, who admitted to the surveyor that she should have removed her gloves and performed hand hygiene before touching any other surfaces. In another instance, RN F was observed performing wound care for a resident admitted with a stage 4 pressure ulcer and a history of wound infection. During the procedure, RN F placed a garbage bag at the end of the bedside table but did not secure it, resulting in the bag falling to the floor and spilling its contents, including soiled dressings and gloves. RN F picked up the trash with the same gloves and continued to handle the resident's belongings, such as the call light and bedside table, without changing gloves or performing hand hygiene. RN F later admitted to the surveyor that she likely forgot to change gloves due to nervousness. The Director of Nursing (DON B) confirmed that the facility's infection control practices were not followed correctly. DON B stated that gloves should be changed and hand hygiene performed when transitioning from dirty to clean tasks, and before and after glove use. The failure to adhere to these practices during wound care procedures was acknowledged by both RN F and DON B, indicating a lapse in maintaining a safe and sanitary environment for residents.
Inadequate Supervision and Security Measures Lead to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and security measures for residents at risk of wandering and elopement, leading to a significant incident involving a severely cognitively impaired resident. This resident, who had a history of exit-seeking behavior, managed to elope from the facility, resulting in a fall and a fractured jaw. The facility's door alarms were not functioning correctly, allowing the resident to navigate through various unsecured areas of the building and exit through an employee entrance without being detected. The facility's policy on elopement and wandering residents was not effectively implemented, as evidenced by the lack of adequate supervision and monitoring of alarm systems. The resident's care plan identified them as an elopement risk, yet the interventions in place were insufficient to prevent the incident. The facility did not have a report or investigation of the initial elopement, and there was no documentation to confirm whether the alarm system was operational at the time. Additionally, other residents at risk for elopement were not adequately protected, as the facility lacked a Wanderguard alarm system on certain floors and did not regularly audit the functionality of existing systems. The facility's failure to monitor and maintain these systems, along with inadequate staff supervision, created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy.
Removal Plan
- All other residents that had the potential for elopement and other safety concerns were assessed and care plans reviewed.
- Maintenance to check the entire wander system to ensure proper functionality. This will include all floors of the facility that contain wander system elements, as well as both the [NAME] and Wanderguard systems.
- All residents that have a Wanderguard will have their Wanderguard bracelet checked to ensure proper functionality. This will include validation of activation dates and a replacement cycle.
- All other residents who have the potential to leave out the doors were assessed.
- Wander books were updated.
- To ensure safety of residents, staff were educated on: Residents at Risk for Elopement, Definition of 1:1, How to check Wanderguards, Standing orders for Wanderguard's implementation, Assigning staff to daily schedule in the event 1:1 is needed who will take 1:1 task.
- Educate staff with a clear understanding of what 1:1 means.
- Educate staff on how to input new standing orders for Wanderguards.
- DON/designee audit conducted to ensure all standing orders for Wanderguards are clear accurate and match for when they need to be changed.
- Audit all Wanderguard bracelets to ensure an accurate date of change.
- All staff will be provided with education regarding the double fire doors near the kitchen, the door at the equipment room, the door at the locker room and the door at the base of the employee entrance that these doors will be mandated always closed.
- Signs were placed on the doors noting the need to keep them closed.
- A secure key code lock will be placed on the equipment room door to ensure residents cannot access staff or unsecure outside exits. A staff person will be designated to monitor this door to prevent a resident from exiting until the key code lock is in place.
- Maintenance will coordinate with a Wanderguard Vendor the possible installation of a Wanderguard sensor at the rear entrance and/or modification to the existing system.
- Maintenance will enhance the lighting in the rear employee parking area/service entrance.
- The facility will complete an initial round of elopement drills on each shift.
- Facility reviewed the following policies: Elopement and Wandering residents, Accidents and Supervision.
- Nursing will test the residents Wanderguard bracelets to ensure functionality weekly going forward. The facility will then audit all resident Wanderguard bracelet tests weekly to ensure compliance.
- The facility will audit the doors identified in the path of egress to ensure closure status.
- Maintenance will test the wander guard sensors at all doors on all floors to ensure proper functionality weekly going forward. The facility will then audit all tests weekly to ensure compliance.
- The facility will review during the daily clinical IDT all residents that demonstrated exit seeking behavior to ensure appropriate elopement interventions are implemented and the care plan is reviewed/revised as necessary.
- R3 and R5 had new elopement risk assessments completed, and it was determined they are no longer at risk.
- All new admissions will have an elopement risk assessment upon admission.
- All current residents will have an elopement assessment and as needed with change.
- Audits will be reviewed at QAPI.
- Facility Assessment will be updated to reflect staffing needs to ensure proper management of individuals with exit seeking behavior.
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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