Edenbrook Sheboygan
Inspection history, citations, penalties and survey trends for this long-term care facility in Sheboygan, Wisconsin.
- Location
- 3014 Erie Ave, Sheboygan, Wisconsin 53081
- CMS Provider Number
- 525568
- Inspections on file
- 46
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Edenbrook Sheboygan during CMS and state inspections, most recent first.
The facility failed to consistently complete timely post-fall assessments with updated VS and to implement care-planned fall-prevention interventions for four residents with dementia, hemiplegia, Parkinson’s disease, diabetes, and other comorbidities. After unwitnessed falls, post-fall assessments were delayed or documented using VS obtained many hours earlier, and required tools such as gripper socks, reachers, and a reminder sign to call for assistance were not consistently in place or within reach. Staff interviews revealed inconsistent understanding of post-fall monitoring practices, including differences in whether standard neuro checks and VS were performed after falls.
The facility did not ensure that residents and their legal representatives were consistently invited to and involved in care conferences as required by its own policy. Over the course of a year, three residents with moderate cognitive impairment and significant medical conditions, including Parkinson’s disease, dementia, stroke history, hemiplegia, type 2 DM, mood disorder, and CKD, had only one or two documented care conferences each, with no evidence that additional quarterly conferences were offered or declined or that their Guardian/POAHC were invited. A POAHC reported not being invited to a care conference for almost a year despite wanting one. The SW acknowledged not consistently using the Care Conference UDA, and the NHA confirmed that care conferences should be attempted at least quarterly and that the UDA should be used per policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after staff failed to follow elopement procedures, including responding to door alarms and conducting a head count. The resident exited through an alarmed stairwell door, which was silenced by a visitor, and was later found by police in a hospital parking lot. Staff were unaware of the resident's absence until notified by authorities.
The facility did not consistently record food and beverage temperatures for multiple meals, with logs showing missing or incomplete entries and some beverages served above the required temperature threshold. Staff interviews confirmed inconsistent practices and lack of a formal policy, resulting in unsafe food storage and preparation.
A resident with severe cognitive impairment eloped from the facility and experienced two falls in one day. The Guardian was not promptly notified of the elopement or the second fall, only being informed after the resident's hip fracture was discovered and hospital transfer was required. Facility staff failed to follow notification policies for changes in condition and incidents affecting the resident.
A resident with severe cognitive impairment and multiple comorbidities experienced two falls in one day. After the second fall, the resident, who complained of hip pain and had a pending X-ray order, was transferred from the floor to bed using Hoyer slings before a comprehensive assessment was completed, contrary to facility policy. Staff and administrator interviews confirmed the resident was moved prior to full evaluation, despite policy requiring assessment for pain and injury before transfer.
A resident with severe cognitive impairment and multiple medical conditions was administered antipsychotic medication without documented attempts at non-pharmacological interventions, as required by facility policy. Staff did not consistently implement or document behavioral strategies before using medications, and the care plan lacked specific guidance for antipsychotic use.
Surveyors found that dietary staff failed to maintain required dishwashing temperatures and did not follow proper hand hygiene protocols during meal service. The dish machine consistently operated below the minimum wash temperature, and staff did not rewash dishes to meet standards. Additionally, dietary aides handled food and touched contaminated surfaces without changing gloves or washing hands, contrary to facility policy and state food code.
A resident with a legal Guardian and multiple diagnoses, including traumatic brain injury and mood disorder, did not have the required court-ordered protective placement documentation in their medical record. Despite communication between facility staff and the Aging and Disability Resource Center, the necessary guardianship documents were not obtained or filed as required by state statute.
The facility did not notify the State Long-Term Care Ombudsman of hospital and ED transfers for two residents, as required by policy. One resident's hospital transfer and another resident's two ED transfers were omitted from the monthly reports, with staff confirming these events were not reported due to oversight and lack of awareness of notification requirements.
Two residents with significant cognitive and psychiatric conditions received new or changed orders for psychotropic medications, including antipsychotics and antidepressants, without the facility updating their PASRR Level I Screens or initiating required Level II evaluations. Staff confirmed awareness of these changes but did not complete the necessary PASRR updates.
A resident with dementia, Parkinson's disease, and a history of multiple falls was not consistently provided the supervision and assistance devices outlined in their care plan. Despite documented needs for limited assist with transfers, supervision during toileting, and a low bed position, staff allowed the resident to ambulate and transfer independently, and the bed was not kept in a low position. Staff interviews revealed inconsistent adherence to the care plan, contributing to repeated unwitnessed falls.
Staff failed to follow infection control protocols for two residents on transmission-based precautions. In one case, a staff member entered a resident's room on droplet precautions without required PPE, and in another, the ADON administered IV medication to a resident on enhanced barrier precautions without wearing a gown, contrary to facility policy.
A resident with multiple health conditions developed a pressure injury due to the facility's failure to provide timely and appropriate wound care. The wound was initially misclassified, delaying necessary interventions, and staff did not correctly transcribe treatment orders, leading to inadequate care. Observations showed the resident was not consistently using required heel boots, resulting in the wound progressing to a stage 4 pressure injury.
A resident with serious health conditions was transferred to the hospital by their POAHC without the facility notifying the resident's physician, as required by policy. The facility only informed hospice staff, which was insufficient according to the Nursing Home Administrator.
The facility did not thoroughly investigate altercations between two residents with severe cognitive impairments. Despite initial responses, there was a lack of documentation for required 15-minute checks on one resident, indicating a deficiency in following abuse prevention protocols.
The facility failed to consistently document oral care for three residents, as required by their policy. One resident with moderately impaired cognition had two days without documented oral care, while another resident with a history of stroke had one day without documentation. A third resident with severely impaired cognition had two days marked as not applicable without explanation. The DON confirmed that undocumented care is considered not done.
The facility failed to provide appropriate catheter care for two residents. One resident's catheter drainage bag was found on the floor, contrary to CDC guidelines, and the facility's policy lacked guidance on proper catheter positioning. Another resident had no catheter care orders or documentation upon admission, and their care plan was delayed. The facility had identified similar issues in a mock survey, but staff education was pending.
A resident with multiple health conditions, including multiple sclerosis and a pressure ulcer, was unable to activate their call light to request assistance due to a malfunction. The issue was confirmed by a surveyor and a CNA, who then reported it for maintenance. The facility's policy requires call lights to be operational at all times.
A resident's wheelchair was found to be visibly dirty, with dried debris and greasy dirt, indicating a failure to maintain a clean, comfortable environment. The NHA stated that night shift CNAs were responsible for cleaning wheelchairs on bath days, but there was no documentation of this task being completed. The resident, who had intact cognition, was unaware if their wheelchair had been cleaned and expressed a desire for it to be cleaned.
A resident with a history of anemia and diabetes mellitus experienced a fall in a facility, resulting in a contusion and shoulder pain. Despite the facility's policy requiring immediate notification of the physician and responsible parties, staff failed to promptly notify the resident's primary care physician or send the resident to the ER. Instead, they contacted an on-call nephrologist from a different medical group, leading to a delay in care. The facility's failure to adhere to its policies and ensure timely medical intervention resulted in a deficiency.
A resident with severe cognitive impairment and a history of mental health issues was left unsupervised, allowing them to crawl out of a second-story window with the intent to jump. Despite a recommendation for 1:1 supervision, the facility failed to ensure adequate supervision, leading to a finding of immediate jeopardy.
The facility failed to properly store, label, and date medications for ten residents, with insulin left unrefrigerated and medication carts unlocked. The refrigerator in the medication storage room was not maintained at the required temperature, and treatment carts contained expired and unlabeled treatments. The Director of Nursing confirmed the facility's failure to track temperature issues and ensure proper storage practices.
Failure to Provide Consistent Post-Fall Monitoring and Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, consistent implementation of fall-prevention interventions, and complete post-fall assessments, including timely vital signs (VS), for four residents. Facility policy dated 1/21/26 required individualized fall-prevention interventions to be implemented consistently and post-fall monitoring with documentation of the resident’s condition at least every shift for 72 hours, including VS and other relevant clinical findings. Despite this, multiple post-fall assessments for several residents lacked updated VS, and some required fall-prevention interventions were not implemented as care-planned. One resident with dementia, hypertension, anxiety, right-sided hemiplegia, and severe cognitive impairment (BIMS 0/15) was at high risk for falls and at risk for bleeding and excessive bruising related to anticoagulant therapy. This resident had an unwitnessed fall in the room on 1/10/26 and was found on the floor, incontinent of urine and unable to report what happened. The fall investigation identified impulsive behavior, decreased safety awareness, and cognitive impairment as root causes, and an immediate intervention was added to ensure gripper socks were on both feet. However, the care plan revised on 1/28/26 did not contain the gripper sock intervention. Post-fall assessments did not begin until approximately 48 hours after the fall, and three of eight documented post-fall assessments used VS obtained many hours earlier rather than updated VS at the time of assessment. Another resident with Parkinson’s disease, anxiety, depression, chronic pain, and moderate cognitive impairment (BIMS 11/15) was care-planned as high risk for falls due to Parkinson’s disease, neuropathy, and dementia with impaired safety awareness. This resident had multiple unwitnessed falls in the room related to impaired safety awareness and attempts to self-transfer or reach for items. For one fall, a CNA Fall Investigation form, which should have included last interaction, items within reach, toileting plan, care plan, and areas for improvement, was not completed. Across three separate falls, ten of thirty-one post-fall assessments did not include updated VS, instead relying on VS taken several hours to more than a day earlier. A third resident with left-sided hemiplegia, dementia, diabetes, mood disorder, and moderate cognitive impairment (BIMS 10/15) was at moderate risk for falls due to left-sided weakness and impaired safety awareness. This resident experienced two unwitnessed falls in the room on the same day while reaching for items. An intervention was added to have two reachers within reach in the room. However, three of ten post-fall assessments lacked updated VS, using earlier readings instead. During observation, the resident was in a wheelchair in the middle of the room with both reachers placed against walls (one by the bed and one on top of supplies near the TV), and the resident demonstrated inability to reach either device. The DON confirmed the reachers were not within reach and stated they should be within reach at all times. A fourth resident with vascular dementia, diabetes, stroke, and moderate cognitive impairment (BIMS 10/15) was at moderate risk for falls due to weakness and dementia. This resident had an unwitnessed fall in the room and could not recall the event. An intervention for a reminder sign to call for assistance before getting up was added to the care plan. Three of ten post-fall assessments did not include updated VS, instead using VS taken several hours earlier. During observation, the resident was seated in the room and no reminder sign was present. The DON later observed the room and stated the sign had been hung near the calendar but must have been taken down or misplaced and was unsure how long it had been missing. Staff interviews showed inconsistent understanding of post-fall monitoring practices: one RN stated the practice was to check residents once or twice per shift without neurological checks, while an LPN stated the facility still did standard post-fall neurological checks with VS at each assessment, and the DON stated policy required assessment once per shift unless otherwise ordered, with additional provider notification for residents on anticoagulants.
Failure to Involve Residents and Representatives in Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure residents and/or their legal representatives were able to participate in the development and implementation of person-centered plans of care, as required by facility policy. The Care Conference policy, revised 6/20/23, states that residents and/or responsible parties are to receive advance communication of scheduled care conferences and that the Interdisciplinary Team (including MDS, nursing, therapy, activities, social services, and dietary) will review key clinical areas and complete a Care Conference User Defined Assessment (UDA) for attendance and discussion tracking. Record review showed that one resident with Parkinson’s disease, dementia, OCD, anxiety, depression, osteoarthritis, and chronic pain, with a BIMS score of 11 (moderate cognitive impairment) and a court-appointed Guardian, had only two care conferences documented in the last year, with no evidence that additional quarterly conferences were offered or declined, and no documentation that the Guardian was invited to quarterly care conferences. Another resident with dementia, left-sided hemiplegia, type 2 diabetes, mood disorder, and chronic kidney disease, with a BIMS score of 10 and an activated POAHC, had only one care conference documented in the last year, with no indication that other quarterly conferences were offered or declined or that the POAHC was invited. A third resident with vascular dementia, history of stroke, and type 2 diabetes, also with a BIMS score of 10 and an activated POAHC, had only one care conference documented in the last year. The POAHC for this resident reported not being invited to a care conference for almost a year, had never refused a care conference, and wanted a conference to discuss the resident’s care. The Social Worker stated that care conference timing is personalized and acknowledged not consistently using the Care Conference UDA per policy, and the Nursing Home Administrator confirmed that care conferences should be attempted at least quarterly and upon request, and that the Social Worker should be using the Care Conference UDA as required by facility policy.
Failure to Supervise and Prevent Elopement for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, was care planned for elopement risk and had a WanderGuard device in place. On the day of the incident, the resident made multiple attempts to exit the unit and was redirected by staff, but no increased supervision was implemented despite the resident's persistent exit-seeking behavior. During a period of high activity with many visitors present, the resident was able to exit the facility through a second-floor stairwell door that was equipped with a functioning alarm. A family member of another resident silenced the alarm and informed staff, who were occupied with other residents and did not follow the facility's elopement procedures. Specifically, staff did not conduct a head count or check the perimeter after being notified of the alarm. As a result, staff were unaware that the resident had left the facility until the police notified them after finding the resident 0.6 miles away in a hospital parking lot, inadequately dressed for the cold weather. Interviews and record reviews revealed that agency staff working that shift had not received orientation or training on the WanderGuard system, and family members had access to alarm codes, allowing them to silence alarms. The facility's investigation was unable to determine exactly how the resident eloped without staff knowledge, but it was clear that staff failed to follow established elopement procedures, including immediate response to alarms, perimeter checks, and head counts. This failure resulted in a finding of immediate jeopardy due to the reasonable likelihood for serious harm.
Removal Plan
- Initiated checks for R1 and updated R1's care plan.
- Changed alarm keypad codes to ensure family members/visitors do not have access to codes or a means to clear alarms.
- Instructed maintenance staff to change the codes at intervals.
- Educated staff on the facility's elopement policy, door alarm system, and new procedure for elevator/door codes.
- Completed elopement drills and tested both systems.
Failure to Maintain Safe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe manner, as evidenced by incomplete and missing food and beverage temperature logs for multiple dates across both the second and third floor dining rooms. Surveyors observed that meal and beverage temperatures were not consistently recorded for breakfast, lunch, or dinner, with entire days and weeks lacking documentation. Additionally, some temperature logs were undated and contained multiple missing entries. During observation, beverage temperatures prior to serving were found to be above the required 41 degrees Fahrenheit, with apple juice and milk measured at 48 to 49 degrees Fahrenheit. Interviews with dietary staff revealed that it was the responsibility of aides present at each meal to record food and beverage temperatures, but this was not consistently done, particularly for dinner service. The dietary aide present confirmed the expectation to record temperatures for all meals and beverages, but acknowledged gaps due to part-time staffing. The Nursing Home Administrator confirmed that staff education on temperature logging had been provided previously, but also stated that the facility did not have a formal policy regarding food temperatures, relying instead on the Wisconsin Food Code.
Failure to Notify Guardian of Resident Elopement and Multiple Falls
Penalty
Summary
The facility failed to notify a resident's court-appointed Guardian of significant changes in the resident's condition and incidents requiring treatment alteration. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia, PTSD, delirium, and anxiety, eloped from the facility without staff knowledge. Staff last observed the resident in the afternoon, but only became aware of the elopement when police arrived after finding the resident at a nearby hospital. The Guardian was not informed of the elopement until several days later, learning of the incident first from the resident's family and Adult Protective Services, rather than from facility staff as required by policy. Additionally, the resident experienced two falls on the same day. After the first fall, the Guardian was notified and an X-ray was ordered due to complaints of hip pain. However, following a second fall later that evening, the Guardian was not informed of this additional incident. The Guardian was only contacted after the X-ray revealed a hip fracture and consent was needed for hospital transfer. Interviews confirmed that staff did not notify the Guardian of the second fall, despite facility policy requiring notification of all changes in condition.
Resident Transferred After Fall Without Required Assessment
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, experienced two falls in one day. After the second fall, the resident was found sitting on the floor, complaining of pain in the right thigh/hip. According to the facility's Post Fall policy, staff are required to conduct a comprehensive evaluation, including assessment for symptoms such as numbness, tingling, or pain, before moving a resident after a fall. If certain symptoms are present, the policy directs staff not to move the resident and to notify a provider or call 911. In this incident, the LPN assisted the resident to a supine position and, with the help of other staff, transferred the resident from the floor to the bed using Hoyer slings before completing a full physical assessment. The nursing progress note and staff interviews confirm that the resident was moved prior to a comprehensive assessment, despite the resident's complaint of hip pain and a pending X-ray order from an earlier fall. The Nursing Home Administrator stated that the facility's policy requires vital signs and pain assessments before transferring a resident unless there are obvious signs of severe injury. However, the administrator was unaware that the injury information pertained to the first fall and that a second fall had occurred. The transfer of the resident from the floor to the bed was performed while the resident was experiencing pain and before the results of the pending X-ray were available, which was not in accordance with the facility's policy.
Failure to Implement Non-Pharmacological Interventions Prior to Antipsychotic Use
Penalty
Summary
A deficiency occurred when the facility failed to prevent the use of unnecessary psychotropic medications for a resident with severe cognitive impairment and multiple medical diagnoses, including cancer, anxiety disorder, and depression. The facility administered antipsychotic medication (haloperidol) to the resident without first implementing or documenting non-pharmacological interventions to address the resident's behaviors, as required by facility policy. The medical record lacked evidence of behavioral assessments, documentation of specific behaviors or symptoms, and the resident's response to non-pharmacological interventions prior to the administration of antipsychotic medication. The resident was bedbound, receiving hospice services, and had a history of restlessness, agitation, and calling out. Staff interviews revealed that the resident was not regularly checked on, did not use a call light, and was not on frequent checks. Although the care plan included interventions such as sensory activities, companionship, and music, these were not consistently implemented or documented. Staff primarily addressed restlessness by offering snacks, water, and repositioning, but there was no evidence that these or other non-pharmacological strategies were attempted or evaluated before resorting to medication. The facility's records showed that the resident received both lorazepam and haloperidol for agitation and restlessness, with medication orders being changed due to perceived ineffectiveness. However, there was no documentation of the required assessments or monitoring for side effects, and the care plan did not include a specific plan for antipsychotic medication use. Staff interviews confirmed that non-pharmacological interventions were not consistently provided or documented, and the facility did not obtain a risks versus benefits statement regarding getting the resident out of bed, despite conflicting information about the resident's preferences and family wishes.
Deficient Food Sanitation and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that food was prepared and served in a safe and sanitary manner, as evidenced by improper dishwashing temperatures and inadequate hand hygiene practices among dietary staff. During multiple observations, the facility's American Dish Service model ADC-44 multi-tank conveyor dish machine did not reach the minimum wash temperature required by both the manufacturer's data plate and the Wisconsin Food Code. Recorded wash temperatures ranged from 150 to 158 degrees F, below the required minimum of 159 degrees F. Despite these substandard temperatures, staff did not rewash dishes to meet the necessary standards, and maintenance staff incorrectly advised that temperatures above 150 degrees F were sufficient. Additionally, dietary staff did not follow proper hand hygiene protocols during meal service. One dietary aide donned gloves without washing hands, touched various surfaces and ready-to-eat foods with the same pair of gloves, and continued serving food with visibly soiled gloves without changing them or cleansing hands. Another dietary aide used hand sanitizer before donning gloves but then touched multiple contaminated surfaces, including a thermometer, sanitizing wipes, and cabinet handles, and scratched their head with soiled gloves before handling food, again without changing gloves or performing hand hygiene. These practices were observed during meal service and confirmed by the Dietary Manager and Corporate Dietitian, who acknowledged that staff failed to adhere to both facility policy and state food code requirements. The deficiencies had the potential to affect nearly all residents in the facility, with the exception of one resident who received nutrition via tube feeding.
Failure to Obtain Required Protective Placement Documentation for Resident with Guardian
Penalty
Summary
The facility failed to ensure that a resident with a legal Guardian had the required court-ordered protective placement documentation, as mandated by State Statute Chapter 55.03(4) for residents whose nursing home stay exceeds 90 days. The resident, who had diagnoses including traumatic brain injury, restlessness and agitation, anxiety, and mood disorder, was admitted with Michigan Guardian paperwork for healthcare decisions. Despite the resident's intact cognition as indicated by a BIMS score of 14 out of 15, the medical record did not contain evidence of the necessary protective placement documentation. Staff interviews and record reviews revealed that the Social Services Director notified the Aging and Disability Resource Center Staff (ADRCS) about the need for protective placement and provided communication records. ADRCS requested specific guardianship documents from the facility, but these were not provided. Further, ADRCS identified that the protective placement paperwork should be filed in the county where the resident previously resided, and attempts to obtain the necessary documents from that county were made. However, the required protective placement documentation was not present in the resident's record at the time of the survey.
Failure to Notify Ombudsman of Resident Hospital and ED Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital and emergency department (ED) transfers for two residents, as required by facility policy. One resident experienced a change in condition and was transferred to the hospital, but this transfer was not included in the monthly report sent to the Ombudsman. The omission was confirmed by the staff member responsible for submitting these reports, who acknowledged that the transfer should have been reported. Another resident was transferred to the ED on two separate occasions due to changes in condition and returned to the facility the same days. These ED transfers were also not included in the monthly report to the Ombudsman. The staff member responsible for notifications indicated a lack of awareness that ED transfers required notification to the Ombudsman, resulting in these events not being reported as mandated by facility policy.
Failure to Update PASRR Screens After Changes in Mental Health Diagnoses and Medications
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level I Screens were updated and, when indicated, Level II Screens were initiated for residents who experienced changes in mental health diagnoses and psychotropic medication orders. For one resident, who had diagnoses including dementia, anxiety, depression, and psychotic disorder, the medical record showed a severely impaired cognitive status and new or changed orders for antianxiety, antipsychotic, and antidepressant medications. Despite these changes, the resident's PASRR Level I Screen was not updated, nor was a Level II Screen completed, as required when new mental disorders or psychotropic medications are identified. Similarly, another resident with multiple neurocognitive and psychiatric diagnoses, including major depressive disorder and anxiety disorder, received new or changed orders for several psychotropic medications, such as antianxiety, anticonvulsant, antidepressant, and antipsychotic drugs. The resident's PASRR Level I and Level II Screens were not updated to reflect these changes. Staff interviews confirmed that the responsible personnel were aware of the medication and diagnosis changes but did not update or resubmit the required PASRR screenings.
Failure to Provide Adequate Supervision and Assistance Devices for Resident with Fall History
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices for a resident with a history of multiple falls. The resident, who had diagnoses including dementia, psychotic disturbance, anxiety, frontal lobe and executive function deficit, Parkinson's disease, and spondylosis, was assessed as not cognitively impaired and had a corporate guardianship for healthcare decisions. The resident's care plan required limited assistance with bed mobility and transfers, supervision with toilet hygiene, and the use of a wheeled walker and gait belt, with the bed to be kept in a low position. Despite these interventions, the resident experienced seven unwitnessed falls over six months, and observations revealed that the resident was allowed to ambulate and transfer independently in their room, with the bed not maintained in a low position as specified in the care plan. Interviews with staff indicated inconsistency in following the care plan, with some staff stating the resident was independent with transfers and toileting, while others noted a preference to assist due to hygiene concerns. The resident reported being independent with these activities, and staff acknowledged that the resident did not always call for assistance as required. The Director of Nursing confirmed that staff are expected to follow residents' care plans, but the observed practices did not align with the documented interventions, contributing to the repeated falls.
Failure to Follow Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program for two of seven sampled residents. For one resident on droplet precautions due to upper respiratory symptoms and a positive rhinovirus test, a maintenance/transport employee entered the resident's room and performed tasks without wearing a mask, gloves, or eye protection, despite clear signage indicating the required personal protective equipment (PPE) and the resident's need for droplet precautions. The staff member's lack of appropriate PPE use was confirmed by both direct observation and staff interviews, and the facility's policy required mask, gloves, and eye protection for droplet precautions. In a separate incident, another resident on enhanced barrier precautions (EBP) for multidrug-resistant organism risk received intravenous medication from the Assistant Director of Nursing, who wore gloves but failed to don a gown as required for high-contact resident care activities under the facility's EBP policy. The EBP signage was posted outside the resident's room, and the staff member acknowledged the omission during an interview. The Director of Nursing also confirmed that administering IV medication is considered high-contact care and requires the use of a gown according to facility policy.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate care and services to prevent pressure injuries from developing and promote healing for a resident. The resident, who had multiple diagnoses including peripheral vascular disease and diabetes, developed a wound on the left foot that was initially misclassified as an arterial wound by a non-wound care certified staff member. This misclassification led to a delay in implementing necessary pressure-relieving interventions, and the wound was not formally assessed until two weeks later. The resident was hospitalized for pneumonia and a UTI, during which the wound was reclassified as an unstageable deep tissue injury. Despite this reclassification, pressure-relieving interventions were not added to the resident's care plan until several days later. Furthermore, the facility staff failed to transcribe a new treatment order correctly, resulting in the wound care not being completed as ordered by the physician. Observations also revealed that the resident was not consistently wearing heel boots as required. These failures in assessment, monitoring, and implementation of appropriate interventions led to the wound progressing to a stage 4 pressure injury, creating a finding of immediate jeopardy. The facility's lack of timely and accurate wound care management contributed to the serious harm experienced by the resident.
Removal Plan
- Educate staff on the Pressure Injury Prevention and Wound Care Management policy, specifically related to physician orders, documentation, treatment completion, implementation of care plan interventions, and how to access the Kardex.
- Conduct a skin sweep of all residents to ensure there are no new areas of skin alteration.
- Conduct a chart audit of all residents with pressure injuries to ensure accuracy of physician orders, treatments are being completed, and care plan interventions are appropriate and effective.
- Implement a system where a second licensed staff is needed to confirm physician orders for accuracy.
- Implement skin and wound audits.
Failure to Notify Physician of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's physician when the resident was transferred to the hospital. The resident, who had a Power of Attorney for Healthcare (POAHC) and was receiving hospice services, was sent to the emergency room by their POAHC due to abnormal behavior and head pain. Despite the facility's policy requiring prompt notification of the attending physician for changes in a resident's condition, the staff only informed the hospice staff and did not notify the resident's physician. The resident, who had moderately impaired cognition and multiple serious diagnoses including malignant neoplasms, was admitted to the facility and later transferred to the hospital without the physician being informed. The Nursing Home Administrator confirmed that the physician should have been notified in addition to the hospice staff, as per the facility's policy. This oversight was identified during a surveyor's review of the resident's medical record and interviews with facility staff.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to ensure a thorough investigation of an allegation of abuse involving two residents, R1 and R2, who had altercations on two separate occasions. The facility's policy mandates timely and thorough investigations of abuse allegations, including documentation of resident behaviors during incidents and investigations. However, the report indicates that the altercations between R1 and R2 on 10/11/24 and 10/13/24 were not thoroughly investigated as required by the facility's policy. R1 and R2 both had severely impaired cognition, with R1 having a BIMS score of 5 and R2 a score of 3, indicating severe cognitive impairment. Despite the facility's initial response to the incidents, including separating the residents and notifying relevant parties, there was a lack of documentation for the 15-minute checks that were supposed to be conducted for R2 following the incidents. This lack of documentation was confirmed by the Nursing Home Administrator, who was unable to provide evidence of the checks, highlighting a deficiency in the facility's adherence to its own abuse prevention and investigation protocols.
Inconsistent Oral Care Documentation for Residents
Penalty
Summary
The facility failed to ensure consistent oral care for three residents, as identified during a survey. The facility's policy requires daily documentation of oral care, including instances of refusal or unavailability. However, for one resident, oral care was not documented as completed for two days, with additional days marked as refused or completed. This resident had moderately impaired cognition and required partial assistance for oral care. Another resident, with moderately impaired cognition and a history of stroke, did not have oral care documented on one day, with the reason for the lack of documentation being unclear. The Director of Nursing (DON) confirmed that if care is not documented, it is considered not done. A third resident, with severely impaired cognition and multiple health issues, did not have oral care documented on two separate days. The documentation for these days was marked as not applicable, and the DON was unable to explain why. The facility's failure to document oral care consistently for these residents indicates a deficiency in adhering to their own policies and procedures for activities of daily living, specifically oral hygiene.
Deficiencies in Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, R9 and R3, as observed by surveyors. For R9, the catheter tubing and uncovered drainage bag were found on the floor, which is against the CDC guidelines that state urinary drainage bags should not rest on the floor. R9 was cognitively intact, with a BIMS score of 15 out of 15, and had a history of multiple sclerosis. The facility's policy did not address the proper positioning of catheter tubing or drainage bags, and the Nursing Home Administrator acknowledged the need to review the policy. For R3, who was admitted with a Foley catheter and had moderately impaired cognition, there was no physician order or documentation for catheter care and output upon admission. R3's care plan did not address the catheter until nearly two weeks after admission, and the Director of Nursing confirmed that catheter care orders and a care plan should have been initiated upon admission. The Nursing Home Administrator noted that a mock survey had identified similar issues, but staff education had not yet been completed.
Deficiency in Call Light Functionality
Penalty
Summary
The facility failed to provide a working call light for a resident, identified as R9, which was observed during a survey. R9, who was admitted with diagnoses including multiple sclerosis, dysphagia, muscle wasting, and a pressure ulcer, had a BIMS score indicating no cognitive impairment. On the day of the survey, R9 attempted to use the call light to request repositioning, but the call light did not activate. The surveyor confirmed the malfunction after R9's second attempt and alerted a CNA, who verified the issue and stated they would contact maintenance for repair. The Nursing Home Administrator acknowledged that call lights should be operational at all times.
Deficiency in Wheelchair Cleaning and Documentation
Penalty
Summary
The facility failed to ensure a clean, comfortable, or home-like environment for a resident, identified as R4, whose wheelchair was found to be visibly dirty. The surveyor observed dried debris on both wheels and a greasy layer of dirt on a bar at the bottom of the wheelchair. Despite attempts to clean it with a glove, some dirt and debris remained. R4, who had intact cognition as indicated by a BIMS score of 13 out of 15, was unaware if the wheelchair had been cleaned and expressed a desire for it to be cleaned. The Nursing Home Administrator (NHA) stated that night shift CNAs were responsible for cleaning wheelchairs on bath days, but there was no documentation to confirm when or if this task was completed. The NHA acknowledged that staff do not document wheelchair cleaning or resident refusals of cleaning. A CNA confirmed that night shift staff were supposed to clean wheelchairs but was unsure if this was documented. The CNA also noted that other wheelchairs in the facility appeared to need cleaning.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide timely care and treatment for a resident who experienced a fall, resulting in a deficiency. The resident, who had a history of anemia and diabetes mellitus, was found face down on the floor with a contusion on the forehead and complained of shoulder pain. Despite the fall and the resident's altered mental status, the facility staff did not promptly notify the resident's primary care physician or send the resident to the emergency room for evaluation. The facility's Change in Condition policy required immediate notification of the physician and responsible parties in such situations, but this was not adhered to. The incident occurred when two CNAs found the resident on the floor early in the morning. The CNAs reported the fall to a nurse, who assisted in transferring the resident back to bed and initiated neurological checks. However, the nurse only documented one set of vital signs and did not perform a complete neurological assessment as required by the facility's policy. The nurse contacted an on-call physician, who was a nephrologist from a different medical group, instead of the resident's primary care physician. This miscommunication led to a delay in sending the resident to the emergency room. The resident's condition was not adequately monitored, and the facility staff failed to follow the proper protocol for notifying the correct medical personnel. The resident was eventually sent to the emergency room later in the morning, but the delay in care and treatment was significant. The facility's failure to adhere to its policies and ensure timely medical intervention contributed to the deficiency identified by the surveyors.
Failure to Provide Adequate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who expressed suicidal ideation and had recently returned from the hospital with a recommendation for 1:1 supervision. The resident, who had severe cognitive impairment and a history of mental health issues, was left unsupervised in a dining room, allowing them to crawl out of an open second-story window and walk along a narrow ledge with the intent to jump. This incident occurred despite the emergency department's instructions for continuous 1:1 supervision upon the resident's return to the facility. The resident's medical history included Alzheimer's disease, vascular dementia, schizoaffective disorder, and schizophrenia, among other conditions. Prior to the incident, the resident had shown signs of mental decline, including hallucinations and suicidal ideation, and had been placed on direct 1:1 observation after attempting self-harm. However, the facility did not ensure that the necessary supervision was in place, as evidenced by the lack of documentation and staff awareness of the 1:1 supervision requirement. Interviews with staff revealed that there was a communication breakdown regarding the resident's supervision needs. The CNA and LPN involved in the incident were not informed of the 1:1 supervision requirement, and the facility's staff schedules did not reflect any assignments for such supervision until after the incident occurred. This lack of supervision and communication created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy.
Removal Plan
- Maintained 1:1 supervision for R1.
- Educated staff on the requirements of 1:1 supervision, checking the schedule to determine who is assigned to 1:1 supervision, and referencing residents' care plans to see which residents require 1:1 supervision.
- Conducted 1:1 shift audits to ensure adequate and safe supervision was provided.
- Conducted staff interviews to ensure 1:1 supervision competency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of medications for ten residents across two medication carts. Observations revealed that insulin vials, which should be refrigerated, were left unrefrigerated, and several medications were found open, undated, and expired. Additionally, the medication carts were not locked when unattended, posing a risk of unauthorized access. The facility's policy mandates that expired medications be removed and that compartments containing medications be locked when not in use. The refrigerator in the medication storage room was not maintained at the required temperature of 41 degrees Fahrenheit or lower, as evidenced by temperature logs showing readings above the acceptable range. The logs also had missing entries, and there was no documentation of maintenance being notified about the out-of-range temperatures. This refrigerator contained unopened insulin vials, which require specific temperature conditions to maintain their integrity. Treatment carts were also found to contain expired and unlabeled treatments and were left unlocked in areas accessible to residents and visitors. The Director of Nursing confirmed that nebulizers should be kept in foil packaging and that insulin should be dated and stored properly. The facility did not track whether maintenance was informed of temperature issues, nor did they ensure that the refrigerators were checked by maintenance when temperatures were out of range.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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