Complete Care At Southpointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenfield, Wisconsin.
- Location
- 4500 W. Loomis Rd., Greenfield, Wisconsin 53220
- CMS Provider Number
- 525604
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Complete Care At Southpointe during CMS and state inspections, most recent first.
A resident with a significant history of prior sacral ulcer repair, flap surgery, skin grafting, ESRD on dialysis, diabetes, morbid obesity, and limited mobility developed a facility-acquired unstageable pressure injury. The facility assessed the resident as low risk, did not document the prior pressure injury surgical history in the care record, and relied on general skin precautions and a pressure-redistribution cushion. When the wound was found, staff documentation was inconsistent about whether it was on the right buttock, left sacrum, or sacrum/buttocks, and the wound RN and APNP later described a much larger unstageable area than the initial nursing measurement.
Inaccurate PBJ staffing data was submitted for a quarter in 2025 after the facility triggered for excessively low weekend staffing affecting all 92 residents. Review of staffing schedules and posting hours did not show weekend coverage gaps, and the Scheduler stated weekend staffing was the same as weekday staffing except for a weekend supervisor not counted during the week. The NHA said the facility changed payroll systems used for PBJ reporting, but no explanation was provided for why the submitted data was not accurate.
The facility failed to follow its abuse, neglect, and exploitation policy requiring timely 4‑year background checks for staff. A CNA had an initial BID form, DOJ letter, and IBIS form completed before hire and another BID form and DOJ letter completed when the facility changed ownership, but no subsequent background check was completed within four years as required. The lapse was identified only after a surveyor requested personnel files, at which point it was determined that the CNA’s most recent documented background check was completed beyond the 4‑year timeframe, potentially affecting a portion of the 97 residents.
Improper Food Storage Temperatures and Labeling: Food storage practices were not in line with facility policy on three units. A refrigerator on one unit was observed at 52 degrees F and another at 34 degrees F, both outside the facility’s acceptable range, while a freezer on another unit had no thermometer and contained an opened, unsealed bag of mixed fruit with no label or date. Staff acknowledged the temperature issues and the unlabeled food when the surveyor pointed them out.
A resident with intact cognition and control of personal finances was found to have been exploited by a CNA who used the resident’s debit card, received cash, linked PayPal accounts, and used the resident’s cell phone. The resident said the card was given to the CNA for food ordering, but later admitted the CNA kept the card and made additional purchases. The facility’s investigation confirmed the CNA admitted to taking money and using the resident’s accounts, while staff education on abuse and misappropriation was incomplete.
A resident with severe cognitive impairment, stroke history, and bilateral hand contractures had active MD orders for both right and left palm guards, but surveyors repeatedly observed the left palm guard not in place. The left device was not listed on the care plan or CNA Kardex, and staff interviews showed confusion about the resident’s splinting needs, while the resident was consistently seen wearing only the right palm guard.
Failure to Notify Ombudsman of Hospital Transfers and Discharges: The facility did not ensure the State LTC Ombudsman was notified of multiple resident hospital transfers/discharges. A monthly discharge/transfer report used for notification did not include several residents who were sent to the hospital after changes in condition, including residents with diagnoses such as colon cancer, dementia, CKD, anemia, heart disease, diabetes, stroke, and acute renal failure. The NHA and SWD stated the report being sent did not capture all residents transferred or discharged to the hospital.
The facility inaccurately coded the MDS for three residents, affecting hospice and smoking status documentation. A resident was marked as not receiving hospice services despite being in hospice care, while two residents were incorrectly documented as non-smokers, contrary to observations and assessments. The MDS Coordinator acknowledged these errors, which did not align with the RAI 3.0 manual guidelines.
A resident with a smoking habit did not have a smoking care plan documented, despite facility policy requiring it. The resident smokes three to four times daily and does not wish to quit. Interviews with the Administrator and Unit Manager confirmed the absence of a smoking care plan, highlighting a failure to adhere to the facility's care planning process.
Failure to Prevent Facility-Acquired Pressure Injury
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and did not prevent a new pressure injury from developing for a resident admitted with a significant history of pressure injuries, including prior sacral ulcer repair, gluteal flap debridement and readvancement, and split thickness skin grafting to the left buttocks. The resident also had morbid obesity, ESRD on dialysis, diabetes, COPD, and impaired mobility. Admission documentation showed the resident was at risk for pressure injury development, had slightly limited sensory perception and mobility, and required moderate to maximum assistance with movement due to friction and shear concerns. Although the resident’s care plan included general skin integrity interventions such as repositioning, pressure relieving devices, and weekly skin checks, the facility did not document the resident’s prior pressure injury surgical history in the care record or incorporate that history into the individualized prevention plan. The resident was assessed as low risk on Braden assessments despite the documented history of prior pressure injury treatment. The resident used a pressure redistribution cushion in the wheelchair and at dialysis, but the facility did not establish resident-specific measures based on the prior flap and graft history before the skin breakdown occurred. On 2/8/26, staff identified an open area during cares and documented it inconsistently as being on the right buttock, right gluteal cleft/sacrum, and sacrum/buttocks. Initial nursing documentation included a small bleeding open area and a measurement of 1.8 cm x 0.2 cm x 0.2 cm, while the wound RN later documented a much larger unstageable wound measuring 11.0 cm x 7.0 cm with slough and epithelial tissue. The wound APNP later described the area as a large unstageable wound on the left side of the sacrum with eschar and noted the resident reported a prior flap repair. Surveyor observations and interviews showed staff continued to document the wound as right-sided while wound specialists assessed it as left sacrum/buttock, and the facility did not recognize the resident’s individualized risk factors before the facility-acquired unstageable pressure injury developed.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility did not ensure that mandatory PBJ staffing data submitted for the fourth quarter of 2025 was accurate based on payroll and other verifiable and auditable data in a uniform format according to CMS specifications. During review of the facility’s PBJ staffing data, the facility was triggered for excessively low weekend staffing, which had the potential to affect all 92 residents. Surveyor review of the facility’s assessment, staffing hours, and acuity levels of care showed the assessment documented staffing ratios needed in the facility and also triggered for low weekend staffing for the quarter in question. Surveyor review of nursing schedules and nurse staff posting hours for that period did not identify documented trends or gaps in weekend staff coverage. In interview, the Scheduler stated weekend staffing was the same as weekday staffing, except for a weekend supervisor who was not accounted for during the week, and explained that the facility switched systems used to report PBJ staffing data in January 2026. The Scheduler was unsure who submitted the data but stated that salaried employees working additional shifts were previously reported through Human Resources and that the new system now captures those staff when they clock in. The NHA stated the facility switched payroll systems used for PBJ reporting starting in September 2025 and fully rolled out the system in January 2026, but no additional information was provided to explain why the submitted staffing data was not accurate.
Failure to Maintain Timely 4‑Year Background Check for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding required 4‑year background checks for employees. The written policy dated 3/2/2026 states that potential employees, contracted staff, students, volunteers, and consultants will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that the facility will maintain documentation proving that such screenings occurred. Record review showed that a CNA hired on 11/2/2020 had an initial Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, and Interagency Border Inspection System (IBIS) form completed on 9/25/2020, prior to employment, but the next documented background check was not completed until 3/10/2026, after the surveyor requested the information. During interviews, the Director of Human Resources acknowledged that when the surveyor requested the CNA’s background check information, it was discovered that no updated background check had been completed within the required four‑year period. The Nursing Home Administrator reported that the facility was purchased by another company in 2022 and stated that all employees had background checks completed in June and July of that year, but at the time of the initial request they were unable to locate the documentation. Later, the Administrator provided a DOJ letter and BID form for the CNA dated 2/10/2022, establishing that a new background check should have been completed by 2/10/2026. The surveyor determined that the background check completed on 3/10/2026 occurred beyond the four‑year timeline and only after it was requested, demonstrating noncompliance with the facility’s abuse prevention screening requirements for one of eight employees reviewed, potentially affecting a portion of the 97 residents in the facility.
Improper Food Storage Temperatures and Labeling
Penalty
Summary
Food was not stored in accordance with professional standards on three unit refrigerators/freezers. On Unit 1, the refrigerator thermometer read 52 degrees F, which was above the facility’s stated acceptable range, even though the temperature log kept at the nurses station documented the refrigerator as consistently 40 degrees F. The RNUM stated temperatures were taken on the night shift and said the thermostat had been turned down after the surveyor pointed out the higher temperature. On Unit 2, the refrigerator thermometer read 34 degrees F, below the facility’s stated acceptable range, and the LPNUM stated the refrigerator was adjusted after the surveyor observed the temperature. On Unit 3, no thermometer was present in the freezer as required by facility policy, and an opened, unsealed bag of mixed fruit was observed in the freezer without a label or date. An LPN present at the time stated there had never been a temperature log for the freezer, and the log only asked for refrigerator temperature. The unlabeled fruit was later discarded after it was observed by survey staff. The NHA was informed of the observations, and the facility later confirmed the concerns were addressed after they were brought to staff attention.
Resident Funds Misappropriation and Exploitation
Penalty
Summary
The facility did not ensure that one resident was free from misappropriation of funds and possible exploitation. The resident had intact cognition with a BIMS score of 13 and was assessed as dependent on two staff for ADLs. The resident was also documented as being their own person and in charge of their own finances. After an anonymous allegation was reported to APS, the facility learned that a CNA had been using the resident’s debit card, receiving cash from the resident, linking the resident’s PayPal account to the CNA’s account, and using the resident’s cell phone. The facility’s own investigation and self-report documented that the CNA admitted getting $400 from the resident, ordering extra food for herself when the resident made food orders, and having the resident’s PayPal account linked to the CNA’s PayPal account. The resident admitted giving the CNA $100, use of a cell phone, and card information. The resident later told the surveyor that the bank card had been given to the CNA so the CNA could already have the information available when the resident wanted to order food, and the resident denied asking for the card back. The resident also stated the facility had provided a locked drawer in the nightstand, but the resident gave the CNA the bank card and it was not taken without the resident knowing. The resident’s trauma assessment documented financial struggle trauma related to not having control of finances and not being aware of the financial situation. The NHA stated the facility called police and initiated an investigation after APS arrived, and that staff interviews did not reveal knowledge of the CNA using the resident’s bank card or taking money. The NHA also stated only about 85% to 90% of staff had been educated on abuse and misappropriation, and the facility had not trained all staff. Surveyor review further noted that after the incident the facility had not assessed or established a plan of care for the resident’s desire to order takeout food and need for staff assistance with ordering, and there was no indication the facility assessed the resident’s need for friendship or loneliness related to the relationship with the CNA.
Failure to Maintain Ordered Palm Guard Use for Resident with Hand Contractures
Penalty
Summary
The facility did not ensure that a resident with limited ROM and bilateral hand contractures received appropriate treatment and services to maintain or improve ROM and prevent further decrease in ROM. The resident had diagnoses including cerebrovascular disease, stroke, gastrostomy tube, and contractures, and the quarterly MDS documented severe cognitive impairment. The resident was dependent on staff for care, mobility, and transfers. The resident had an active MD order for a left hand palm guard to be worn 24 hours a day, with removal allowed for hand hygiene, and a later order for a right palm guard. The resident’s contracture care plan included the right palm guard, but the left palm guard intervention had been resolved from the care plan and was not listed on the CNA Kardex. Surveyors observed the resident multiple times over several days lying in bed with the right palm guard in place but without the left palm guard. The resident’s left hand was described as contracted and, at one observation, partly hanging off the bed. Staff interviews showed confusion about which hand required which device. A CNA stated the resident was supposed to wear a palm guard on the right hand and referenced the CNA Kardex for brace and splint information. An LPN stated both hands had been using palm guards or carrots, then confirmed the resident should be wearing a left palm guard after checking the record, but also noted the left device was not in place during the observation and that a carrot had been placed in the left hand earlier and later found under the bed. Additional interviews confirmed that the left palm guard order had not been discontinued when the right palm guard was added. The OT stated the resident had worn a left palm guard since 2024 and should have both devices in place. The DON stated the left palm guard should have been care planned after being informed that the resident had an active order and that the device was not on the resident during survey observations. The report states the resident’s left palm guard was not part of the active comprehensive care plan or CNA Kardex despite the continuing MD order and repeated observations that it was not in place.
Failure to Notify Ombudsman of Hospital Transfers and Discharges
Penalty
Summary
The facility did not ensure that proper notification was sent to the State Long-Term Care Ombudsman for residents who were transferred or discharged to the hospital. The report identified 6 residents reviewed for transfers or discharges, including R1, R2, R3, R8, R10, and R103, and found that their hospitalizations were not included on the discharge/transfer report provided as evidence that the Ombudsman had been notified. The Nursing Home Administrator and Social Work Director stated that the monthly report was being sent by email, but the report used did not capture all residents transferred or discharged to the hospital. R1 was transferred to the hospital twice for further evaluation after changes in condition, including one transfer on 8/5/25 and another on 10/23/25, and neither hospitalization appeared on the report. R2 was transferred to the hospital on 11/5/25 after a change in condition, and that hospitalization was also missing from the report. R3, who had diagnoses including colon cancer, colostomy, stroke, and type 2 diabetes, was transferred to the hospital on 12/8/25 after a change in condition, but that hospitalization was not listed on the report sent to the Ombudsman. R8, who had diagnoses including Alzheimer’s, dementia, stage 3 chronic kidney disease, and anemia, was transferred to the hospital on 10/13/25 after a change in condition, and this hospitalization was not included on the report. R10, who had heart disease and type 2 diabetes, was transferred to the hospital on 11/21/25 after a clinic visit with a change in condition and again on 2/13/26 for a planned surgical procedure; neither hospitalization was listed. R103 was transferred to the hospital on 1/8/26 for a change in condition and was admitted for acute renal failure, did not return to the facility, and was not included on the discharge/transfer list reviewed by the surveyor.
Inaccurate MDS Coding for Hospice and Smoking Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to potential missed opportunities for care or services. Resident 23 was marked as not receiving hospice services on their quarterly MDS, despite progress notes indicating they were receiving hospice care until their passing. This discrepancy highlights a failure in accurately reflecting the resident's care status in the MDS. Resident 27 was incorrectly marked as a non-smoker on their annual MDS, although observations confirmed they smoked independently in the designated area. Additionally, Resident 89's admission MDS inaccurately documented them as a non-smoker, despite their smoking assessment and inclusion on the facility's list of smokers. The Minimum Data Set Coordinator acknowledged these coding errors, which were contrary to the guidelines outlined in the Resident Assessment Instrument (RAI) 3.0 manual.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified with smoking behaviors. The facility's policy requires that all safe smoking measures be documented in each resident's care plan. However, a review of the resident's care plan did not reveal any documentation of a smoking care plan, despite the resident's admission smoking assessment indicating that the resident smokes three to four times a day and does not wish to quit smoking. Interviews with the facility's Administrator and Unit Manager confirmed the absence of a smoking care plan for the resident. The Administrator noted that the resident only smokes with family members who maintain his cigarettes, which should have been documented in the care plan. The Unit Manager acknowledged that the smoking care plan was not developed, indicating a lapse in adhering to the facility's policy and comprehensive care planning process.
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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