Glenhaven
Inspection history, citations, penalties and survey trends for this long-term care facility in Glenwood City, Wisconsin.
- Location
- 612 E Oak St, Glenwood City, Wisconsin 54013
- CMS Provider Number
- 525602
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Glenhaven during CMS and state inspections, most recent first.
A resident at risk for PI development had a buttock wound that progressed from redness to an open area with slough, while staff failed to provide consistent wound care, off-loading, and complete care plan interventions. Surveyors observed the resident sitting directly on the buttocks in a recliner and wheelchair without a pressure-relieving cushion, and an RN applied zinc oxide to the open wound with contaminated gloves instead of following the ordered dressing care. Hospice notes also showed the wound deteriorated from stage 1 to stage 2 and then to unstageable, with only verbal off-loading instructions and no documented interventions in the care plan.
Food and beverages were not held at safe, appetizing temperatures. Resident council minutes and a resident interview showed ongoing complaints that meals were cold. During meal observation, hot foods were found at 98, 130, 70, and 47 degrees, while drinks were passed between units without temperature control and later measured at 71 degrees. The DON stated food should have been reheated to 165 degrees or higher before service, and that the warmer could not hold all of the food with the current census.
Unsanitary food handling, storage, and transport practices were observed. A Dietary Aide was seen moving between dirty and clean dishes without hand hygiene or proper apron use, and staff handled ready-to-eat foods, utensils, and trays with contaminated gloves or after changing gloves without hand antisepsis. Surveyors also found unlabeled food items, open foods without dates, a scoop stored in a food container, and an uncovered dessert tray carried through hallways and delivered to residents.
Surveyors found unsafe Hoyer lift practices and inconsistent supervision of thickened liquids. A dependent resident was transferred with only one CNA and the wrong sling size was not clearly assessed, while two other residents were also lifted with one-person assistance despite guidance calling for two trained staff. In addition, a resident with dysphagia and impaired cognition had conflicting diet orders in the chart, staff were unsure whether honey or nectar thick liquids were ordered, and thickened liquids were observed left at the bedside without consistent supervision.
A resident with no cognitive impairment was admitted without a code status order in place, and the medical record did not clearly identify the resident’s advance directive on admission. Survey review found no scanned DNR document, RN staff said code status should be addressed within 24 hours, and the DON acknowledged staff had believed the resident was Full Code until the DNR status was later recognized.
Failure to report suspected sexual abuse allegation: A resident with mild to moderate cognitive impairment and significant toileting assistance needs reported that a male CNA touched his penis while he was sleeping. Staff notified the DON, gathered statements, and spoke with the POA, but the allegation was not reported to the SA/MIR system or law enforcement as required by policy and state reporting requirements.
A resident with cognitive impairment and extensive toileting assistance needs reported that a CNA touched his penis while he was sleeping. The facility relied on the POA’s belief that the allegation was not true, did not complete a thorough abuse investigation, and allowed the accused CNA to keep working and continue caring for the resident and other unit residents while the matter was being reviewed. The DON later stated the investigation should have been more thorough.
Incomplete Transfer/Discharge Notices: The facility did not ensure that two residents or their representatives received proper written transfer/discharge notices with a specific reason for transfer and required Ombudsman information. Review found the forms used only general options such as resident choice or urgent medical need, and the notices for both residents’ hospitalizations did not state a specific reason for the move.
Late MDS Assessments and Submissions for Two Residents: The facility failed to complete and transmit required MDS assessments within regulatory time frames for two residents. One resident had multiple late comprehensive, quarterly, PPS, and tracking records, while the other had late tracking, admission/Medicare 5-day, and PPS discharge assessments. The ADON/MDS coordinator stated that a readmission had not gone through in the system and was surprised to learn some assessments were late.
Failure to Provide Timely Incontinence Care: A resident who was dependent for all ADLs, incontinent of urine, and unable to reliably communicate was observed with a brief that was checked in the morning but not changed, then left unassessed until early afternoon. The resident’s care plan directed checks every 2 to 3 hours and peri-care after each incontinent episode, yet the brief was found fully saturated when finally changed by two CNAs. Staff interviews confirmed the usual expectation was to check and change every 2 hours or as care planned.
Failure to Reposition Two Dependent Residents: The facility did not ensure two dependent residents received repositioning and pressure offloading per their CNA Kardex and care needs. One resident with dementia, impaired mobility, and total dependence for ADLs was observed in a wheelchair for hours without being repositioned or returned to bed or a recliner, and another resident with aphasia, stroke history, hemiplegia, morbid obesity, and severe cognitive impairment was also observed sitting for hours without repositioning. CNA staff and the ADON stated residents unable to reposition themselves should be checked and repositioned every 2 hours, and the DON stated this was the expected care plan.
A resident with an indwelling catheter, neurogenic bladder, and a history of UTI was observed with a leg bag positioned above the knee, kinked, and wrapped around the knee, with the catheter pulling tightly at the penis and no thigh securement in place. Hematuria was seen in the bag, and the resident later complained of severe pain in the groin and bottom area. CNA and nursing staff confirmed the catheter should have been secured to the thigh and kept free of kinks.
Improper Storage and Labeling of Medications: A surveyor observed a resident's liquid morphine on a unit E med cart with no open date label after it had been opened, and also found lorazepam stored in a refrigerator inside a locked cabinet with other medications rather than in a separately locked compartment. The RN was unsure about the storage requirement, and the ADON stated the controlled medication should have been locked separately.
A resident with severe cognitive impairment and on anticoagulant therapy was found with multiple bruises of unknown origin. The facility's investigation focused on the resident's elevated INR and possible contact with hard surfaces, but did not include comprehensive skin checks for other non-interviewable residents or fully explore other potential causes, such as recent behavioral incidents or the use of compression stockings. The investigation was concluded without a thorough assessment of all possible sources of the bruising.
A resident with severe cognitive impairment and multiple medical conditions was found with multiple bruises on her arms and legs after receiving care. The facility did not determine the cause of the bruising, failed to update the care plan with interventions to prevent recurrence, and did not provide staff education on preventing injuries, despite identifying possible causes such as compression stockings, hard surfaces, and resident combativeness. No new measures were implemented to address these hazards or protect the resident from further injury.
A resident with severe cognitive impairment struck another resident after a verbal exchange. Although the incident was reported to the state agency and investigated internally, facility staff did not notify local law enforcement as required by policy, citing the absence of injury and the perceived minor nature of the incident.
Following a physical altercation between two residents with severe cognitive impairment, the facility did not conduct interviews with other residents as required by policy, resulting in an incomplete investigation of potential abuse. The DON stated that the event was considered isolated, despite both residents having access to others.
A resident with severe cognitive impairment and multiple comorbidities experienced an increased fall risk and several falls, including one with injury, but the facility did not update the care plan with new interventions as required by policy. The only change made was the addition of a bed alarm, and the care plan continued to note only that the resident was likely to ambulate, without further strategies to address the increased risk.
The facility failed to follow food safety standards, as a dietary aide did not check the temperature of a resident's microwaved meal before serving. Additionally, the kitchen inspection revealed improperly labeled and stored food items, and an uncleaned deep fryer. The dietary manager acknowledged these issues, indicating a lack of adherence to food safety protocols.
The facility submitted inaccurate staffing data to CMS, failing to record RN hours and 24-hour nursing coverage due to coding errors. The Director of Nursing and MDS Coordinator, both RNs, covered shifts but were not coded correctly, affecting all residents.
The facility failed to establish a comprehensive Infection Control Program, leading to deficiencies such as an inadequate water management process for Legionella prevention, incomplete infection surveillance logs, and improper implementation of Transmission-Based Precautions for a resident with pneumonia. Additionally, the facility's handling of infectious linens was insufficient, with staff not using appropriate PPE. These issues were acknowledged by the ADON and NHA.
A facility failed to implement a comprehensive care plan for a resident on Warfarin, an anticoagulant, to address bleeding risk. Despite the resident's diagnoses of dementia, atrial fibrillation, and hypertension, and daily anticoagulant use, the care plan lacked specific guidance. Interviews revealed concerns from the resident's POA and staff about the absence of formal documentation and monitoring protocols for bleeding risk.
A resident admitted without skin impairments developed a stage 2 pressure injury due to inadequate care planning and repositioning. Despite being at high risk, the facility failed to implement a turning/repositioning program or address skin integrity concerns in the care plan. Observations showed the resident was left in the same position for extended periods, and inappropriate cleansing techniques caused further injury. Staff interviews revealed a lack of consistent interventions, and the care plan was not updated promptly.
The facility failed to provide adequate supervision and assistance to residents identified as fall and choking risks. A resident with a history of falls was observed ambulating alone without required assistance. Another resident self-transferred without staff help, and a resident at risk of choking was left unsupervised during meals. The ADON confirmed these lapses in care.
A resident with an indwelling Foley catheter did not receive care consistent with professional standards, as the catheter was changed monthly without clinical indications, contrary to CDC guidelines. The ADON could not provide a physician's reason for this routine change, acknowledging awareness of the standard practice, which was not followed in this case.
A facility failed to provide necessary social services for a resident with PTSD, anxiety, and depression. The resident's care plan lacked a PTSD-specific plan, and there were no documented non-pharmacological interventions. The resident expressed dissatisfaction with the emotional support, noting the absence of a dedicated social worker and reliance on medication. Observations showed the resident often remained in bed, appearing depressed. Interviews with staff confirmed the lack of a PTSD care plan and behavior monitoring, with no documentation of interventions in the resident's EHR.
The facility did not ensure a proper communication process with the hospice provider for a resident, as there was no communication binder available to relay information regarding hospice services. The ADON admitted the absence of the binder, which is typically used for communication, and the hospice provider does not have access to the facility's Electronic Medical Record.
Failure to Provide Consistent Pressure Injury Care and Off-Loading
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent further deterioration of an existing pressure injury for a resident with multiple diagnoses including parkinsonism, depression, anxiety, type 2 diabetes, and neuromuscular dysfunction of the bladder. The resident was assessed as being at risk for pressure injuries on the MDS and had care plans addressing skin integrity and bed mobility. Facility records showed the resident initially had normal skin on admission, later developed redness to the coccyx/buttock area, and then progressed to an open area on the buttock with drainage and worsening wound status over time. The record showed inconsistent wound care and incomplete documentation of the wound’s progression. Nursing notes documented a reddened but intact backside, then a stage I sacral pressure injury, later a dark red blanchable area on the buttock, and then a small open area in the intergluteal crest. Orders were entered for dressing changes to the right buttock, but survey observations found the resident lying in a recliner with the buttocks touching the chair and no pressure-relieving cushion in place. Staff also observed the resident sitting directly on the buttocks in the recliner and wheelchair, and staff reported the resident was to be repositioned at least every 2 hours. During observation, the resident had loose incontinent bowel movements, severe pain to the buttocks and groin, and an open wound on the left buttock with 100% slough. The surveyor observed a CNA and RN cleaning stool from the resident’s buttocks, but the RN applied zinc oxide to the open wound with contaminated gloves and did not perform hand hygiene before continuing care. The RN stated the facility did not have a small enough Mepilex dressing and therefore used zinc oxide instead of the ordered dressing. The ADON acknowledged that the ordered Mepilex should have been placed and that the RN should have removed contaminated gloves and sanitized hands before donning new gloves. Hospice documentation also showed the wound had been assessed as a pressure injury that deteriorated from stage 1 to stage 2 and then to unstageable with slough, while hospice staff reported that off-loading interventions were only verbally communicated and were not placed in the medical record or care plan at that time.
Food and beverages not held at safe serving temperatures
Penalty
Summary
The facility failed to provide palatable food served at safe, appetizing temperatures. Resident council meeting minutes from December 2025 through February 2026 documented repeated resident concerns that food temperatures were cold or on the colder side. During an interview, one resident reported that the resident’s food is always cold, and during a resident council meeting, residents stated that sometimes food is too cold. During meal observation, the surveyor saw the meal cart arrive to the unit and items placed in the hot holding area, while cranberry juice, lemonade, water, milk, and other juices were passed from unit to unit without temperature control measures. The dietary aide took temperatures of hot-held foods and found a cheese steak sandwich at 98 degrees, carrots at 130 degrees, pureed potatoes at 70 degrees, and another pureed starch at 47 degrees. The pureed food items were left on the counter with no temperature control in place, and no action was taken to bring the foods up to proper holding temperatures before service. Later, fluids were placed back into the refrigerator, and one fluid temperature was taken at 71 degrees. The dietary director stated that food should have been reheated to 165 degrees or higher prior to service and that all food was supposed to be in the warmer, but there was more food than would fit with the current census.
Unsanitary food handling, storage, and transport practices
Penalty
Summary
The facility failed to prepare and distribute food under sanitary conditions. During dishwashing, a Dietary Aide was observed spraying dirty dishes and getting water and debris on the front of her uniform while not wearing the disposable apron described in facility policy. The same staff member moved from dirty dishes to clean dishes without changing gloves or performing hand hygiene, and another Dietary Aide was observed removing gloves and putting on clean gloves without hand hygiene. The Dietary Director stated staff should wear a disposable apron, have a dirty person and a clean person when doing dishes, or stop and wash hands before handling clean dishes. During meal preparation and service, a Dietary Aide was observed handling utensils, milk, bread, toast, butter, jelly, fruit, and trays with the same contaminated gloves while preparing and delivering resident meals. The aide touched a toaster, door handles, and other surfaces, then continued preparing ready-to-eat foods without changing gloves or washing hands. Another Dietary Aide was observed changing gloves without performing hand antisepsis while making pancakes. The Dietary Director stated that when staff change tasks, hands should be washed and gloves changed. Food storage and transport practices were also observed to be unsanitary. In the kitchen and storage areas, surveyors found unlabeled food items, including a container of pears in the refrigerator, containers of sugar, flour, and another powder, a half-open loaf of bread, and an open package of hamburger buns without labels or open dates. A scoop was stored in a container of salt, and the Dietary Director stated scoops should not be left in containers. In addition, a tray of desserts was carried uncovered down hallways and from unit to unit and delivered to residents uncovered, with a CNA acknowledging the tray should have been covered even though the kitchen had forgotten to deliver the desserts.
Unsafe Hoyer Lift Transfers and Inconsistent Supervision of Thickened Liquids
Penalty
Summary
The facility did not ensure residents remained free of accidental hazards during mechanical lift transfers and while receiving thickened liquids. Survey observations and interviews showed that staff used Hoyer lifts for dependent residents without consistent use of two staff members, and staff also did not consistently ensure the correct sling size was used. The report cites facility policy stating total lifts are used for non-weight-bearing residents and that mobility tasks such as rolling and boosting should be performed in teams of two, along with OSHA guidance that Hoyer lifts in nursing homes require at least two trained staff members and the correct sling size and type. R13 was admitted with diagnoses including unspecified mood disorder, essential tremors, hearing loss, dementia, and hypertension. The MDS showed unclear speech, inability to respond to BIMS questions, impaired mobility in both upper and lower extremities, dependence for rolling, and dependence on a mechanical lift for all transfers. The CNA Kardex directed use of a medium sling and dependent 1-2 assist full body/Hoyer lift. However, the surveyor observed only one CNA transfer R13 from bed to wheelchair with a Hoyer lift and roll the resident side to side to place the sling under him. The record review found no height documented and no progress note or assessment documenting how Hoyer sling size was determined. R5, who had diagnoses including aphasia, stroke history, hemiplegia and hemiparesis, morbid obesity, seizure disorder, diabetes, muscle weakness, hypertension, dementia, and depression, was also transferred with a Hoyer lift using a large sling. R23, who had diagnoses including a progressive neurological condition, CAD, heart failure, dementia, anxiety, depression, and asthma, was observed being transferred by only one CNA with a Hoyer lift, and the CNA stated that although two staff are usually used, the lift is safe with one person and sometimes it is too busy. The surveyor also observed sling sizes used with R5, R13, and R23 and noted overlap in the manufacturer’s sizing chart, with staff stating sling size was based on the plan or weight rather than a documented resident-specific assessment. The facility also did not ensure adequate supervision for R14, who had diagnoses including cerebral infarction, glaucoma, osteoarthritis, flaccid hemiplegia, depression, muscle weakness, lymphedema, facial weakness following cerebral infarction, and urinary tract infection. R14’s MDS indicated set-up and supervision during eating, and the care plan called for puree texture and honey thick liquids with supervision at meals. The ST order later documented nectar thick liquids in nosey cups and pureed foods, but staff interviews showed confusion about whether R14 should receive honey or nectar thick liquids and whether fluids could be left in the room. Survey observations found thickened liquids sitting on R14’s bedside table on more than one occasion, while staff gave inconsistent answers about the diet order and supervision expectations.
Advance Directive and DNR Status Not Clearly Documented on Admission
Penalty
Summary
The facility did not ensure that one sampled resident’s medical record clearly identified advance directives, specifically code status, on admission. The resident was admitted after a hospitalization and had a Brief Interview for Mental Status score of 15/15, indicating no cognitive impairment. Admission physician orders did not include a code status order, and survey review found no advance directive scanned into the electronic record at the time of review, while a DNR physician order was not completed until 7 days after admission. During the survey, the resident stated to the surveyor that she was a DNR. RN J reported that the admitting floor nurse was expected to address code status within 24 hours of admission, but when reviewing the record, RN J found no code status in place on admission and no scanned documentation showing a signed DNR document. DON B stated that the admission process began with paperwork completed by the Administrative Assistant and then sent for provider signature, but acknowledged that staff had believed the resident was Full Code until the Health Unit Coordinator returned from vacation and the DNR status was recognized. DON B also confirmed that the advance directive document was not yet scanned into the resident’s medical record when shown to the surveyor.
Failure to Report Suspected Sexual Abuse Allegation
Penalty
Summary
The facility failed to report a suspected abuse allegation involving a resident to the State Agency through the State's Misconduct Incident Reporting system immediately upon learning of the incident. The resident, who was admitted with diagnoses including urinary tract infection, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of the bladder, GERD, and insomnia, had an MDS assessment showing substantial to maximal assistance needs for toileting and toilet transfer, and a BIMS score of 8/15 indicating mild to moderate cognitive impairment. The facility policy required alleged abuse to be reported immediately, and no later than 2 hours after the allegation if abuse was involved or serious bodily injury resulted. According to the resident's progress notes, the resident told staff that a male CNA had come into the room while he was sleeping and touched his penis. The note states the resident clarified that the touching was on top of the brief and that the CNA slid his hand up and down. Staff notified the DON, obtained statements, and contacted the POA, who said the resident had made similar statements before and that the CNA had not done anything wrong. The facility's analysis and action plan worksheet documented no notification to law enforcement and no notification to the MD. During interview, the DON stated that the allegation was not reported to the State or law enforcement as it should have been.
Failure to Thoroughly Investigate Sexual Abuse Allegation and Protect Resident
Penalty
Summary
The facility did not ensure allegations of sexual abuse were thoroughly investigated or that further potential abuse was prevented while the investigation was in progress for a resident who required substantial to maximal assistance with toileting and toilet transfer and had mild to moderate cognitive impairment. The resident reported that a CNA came into the room while he was sleeping and touched his penis, stating the contact was on top of the brief and that the CNA slid his hand up and down. The resident also stated he would call his son and be out of there by morning. The resident’s POA told staff the resident had made similar statements before and that she believed the allegation was not true. After the allegation was reported, the facility documented that staff obtained statements from CNAs and the POA, and the DON advised that the resident would be care-planned as making false accusations and that the accused CNA would no longer be assigned to the resident. The facility’s analysis and action plan stated that no state report would be submitted because the POA said the accusation was not accurate. The record also noted that other residents on the unit were questioned, including those unable to answer who were assessed for behavior changes, but the facility could not provide a head-to-toe assessment for the resident or assessments for cognitively impaired residents cared for by the accused CNA. Interview findings showed the accused CNA continued to work the rest of the shift and the next two days, and continued to care for the resident and other residents on the unit. The DON stated the facility felt the accusation was not accurate because the resident hallucinated and the POA said it was probably not accurate. The DON also reported that the investigation was not as thorough as it should have been and that no education was provided to the CNA after the incident.
Incomplete Transfer/Discharge Notices
Penalty
Summary
The facility did not ensure that two residents or their resident representatives received proper written notice of transfer or discharge, including the reason for the transfer and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. Survey review found that the facility’s transfer/discharge notices did not contain a specific reason for transfer, and the blank forms provided by the facility included only general options such as resident choice, need for a higher level of care, or urgent medical need rather than a specific explanation. For R30, who was admitted with diagnoses including high blood pressure, high cholesterol, chronic fatigue, squamous cell carcinoma of the skin, type 2 diabetes with chronic kidney disease, communication disorder, bipolar disorder, dementia, and Alzheimer’s disease, the MDS showed cognitive impairment and dependence for multiple activities of daily living. Review of transfer notices for R30’s hospitalizations showed no specific reason for transfer to a higher level of care. For R2, who had diagnoses including urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of the bladder, GERD, and insomnia, the MDS and BIMS showed substantial assistance needs and mild to moderate cognitive impairment. Review of transfer notices for R2’s hospitalizations showed no reason for transfer to a higher level of care.
Late MDS Assessments and Submissions for Two Residents
Penalty
Summary
The facility did not complete and submit Minimum Data Set (MDS) assessments within the required time frames for 2 sampled residents, R30 and R2, during the survey period. The report states that for non-admission MDSs, the completion date must be no later than 14 days after the previous ARD, and for admission assessments, the completion date must be no later than 13 days after the entry date. It also states that quarterly assessments must have the ARD and completion date no later than 92 days from the previous ARD, with transmission no later than 14 days after completion. R30 had multiple late assessments and transmissions, including an annual comprehensive assessment, quarterly assessment, PPS assessment, and tracking record that were completed or submitted beyond the required time frames. R30 was admitted with diagnoses including high blood pressure, high cholesterol, chronic fatigue, squamous cell carcinoma of the skin, type 2 diabetes with chronic kidney disease, communication disorder, bipolar disorder, dementia, and Alzheimer's disease. R2 also had late MDS submissions, including a tracking record, a comprehensive admission/Medicare 5-day assessment, and a PPS/Part A discharge assessment. R2's diagnoses included urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of bladder, GERD without esophagitis, and insomnia. The ADON, who was also the MDS coordinator, stated that a readmission for R30 had not gone through in the system and said she was surprised to learn that some assessments were late.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility did not ensure timely incontinence care and repositioning for a resident who was dependent for all activities of daily living and incontinent of urine. The resident had diagnoses including unspecified mood disorder, essential tremors, hearing loss, dementia, and high blood pressure, and the MDS indicated the resident had unclear speech, was never understood, and rarely understood conversation. The resident was dependent for mobility, transfers, toileting hygiene, personal hygiene, dressing, and used a mechanical lift for transfers and a wheelchair for mobility. The resident’s care plan and Kardex directed staff to check and change the brief every two hours and as needed, and the incontinence care plan directed staff to check the resident every two to three hours and provide peri-care after each incontinent episode. On the morning of the observation, a CNA transferred the resident to the wheelchair at 7:10 AM and stated the resident’s cares had already been done. The resident was then observed in the great room, at breakfast, in the activity area, and at lunch, with staff checking the brief at 10:02 AM and stating the resident was dry, but not changing the brief at that time. The resident was not checked again for incontinence until 2:02 PM, when two CNAs transferred the resident back to bed and changed the brief. At that time, the brief was saturated and ready to break, and all markings were blue indicating full saturation. During interviews, CNAs stated residents are generally checked every two hours, and the ADON stated the resident should have been checked before lunch if checked at 10:00 AM and that the expectation was to change and reposition every two hours or as care planned. The DON later stated the expectation was for residents to be changed and repositioned every two hours or as care planned.
Failure to Reposition Two Dependent Residents
Penalty
Summary
The facility did not ensure that two dependent residents, R13 and R5, received repositioning and related care according to their care plans and standards of care. On 3/4/26, the surveyor asked for policies on incontinence care, ADL dependency, and repositioning, and the DON stated she could not find a policy on incontinence care and repositioning. R13 was admitted with diagnoses including unspecified mood disorder, essential tremors, hearing loss, dementia, and high blood pressure. His MDS showed unclear speech, inability to respond to BIMS questions, impaired mobility in both upper and lower extremities, and dependence for all mobility and ADLs. His CNA Kardex directed incontinence checks and changes every two hours and as needed, and assistance with repositioning, but did not give a frequency for repositioning. The surveyor observed R13 in a wheelchair from 7:10 AM until 2:02 PM without being repositioned or placed back in bed or a recliner to offload pressure to his buttocks. R5 was admitted with diagnoses including aphasia, history of stroke, cellulitis of the right lower limb, hemiplegia and hemiparesis, morbid obesity, seizure disorder, type 2 diabetes mellitus, muscle weakness, hypertension, dementia, and depression. His MDS indicated unclear speech, severe cognitive impairment based on staff assessment, substantial assistance needed for all mobility, and a history of one pressure injury with risk for others. His CNA Kardex directed turning and repositioning every two hours and PRN, keeping body in good alignment, and transferring him to bed between meals to offload pressure from the buttocks. The surveyor observed R5 in a chair from 8:36 AM until 1:50 PM without being repositioned or placed back in bed or a recliner. CNA T stated R5 was repositioned every two hours but later acknowledged he had been up in his chair all day and that he should have been asked again and repositioned. The ADON stated residents unable to reposition themselves should be checked every couple hours and that they should not have gone 8-10 hours in one position, and the DON stated residents would be expected to be changed and repositioned every 2 hours or as care planned.
Improper Catheter Securement and Kinked Tubing
Penalty
Summary
The facility did not ensure appropriate care and services for a resident with an indwelling catheter. The resident had diagnoses including urinary tract infection, Klebsiella pneumoniae, parkinsonism, depression, anxiety, hyperlipidemia, type 2 diabetes, neuromuscular dysfunction of the bladder, gastroesophageal reflux disease, and insomnia. The resident’s MDS showed substantial maximal assistance was needed for toileting and toilet transfer, and the BIMS score indicated mild to moderate cognitive impairment. The care plan directed that the catheter bag and tubing be positioned below the bladder and that the catheter be monitored for signs and symptoms of discomfort and UTI. During observation, the resident’s leg bag was found sitting above the knee, kinked and wrapped around the knee, with the catheter pulling tightly from the coronal area of the penis and no stabilization to the thigh. Hematuria was observed in the leg bag, and the resident was later seen shaking and complaining of severe pain in the bottom and groin area. CNA E stated the hospice CNA had provided care earlier and was unsure why the leg bag was so short and not stabilized. Hospice RN F stated the catheter should be secured to the thigh and that proper tubing should be used so it would not kink, and reported the catheter was pulling at the penis when she assessed the resident. ADON C also stated the catheter should be secured to the thigh and the tubing should not be kinked.
Improper Storage and Labeling of Medications
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in 1 of 3 medication carts/storage rooms observed. During the recertification survey, the surveyor observed a bottle of liquid morphine sulfate for R15 on the unit E medication cart that had been opened but did not have an open date label. The morphine was dispensed on 12/26/25, and R15 had used 2 doses on 02/14/26 and 02/17/26. The bottle was kept in a bag with R15's identification, but no open date was present when the surveyor observed it. The surveyor also observed controlled medication storage on unit E and found a lorazepam vial in a refrigerator inside a locked cabinet with insulin pens and flu vaccinations. The surveyor asked whether lorazepam was supposed to be double locked, and the RN stated she was unsure. The ADON later stated that lorazepam should be locked and believed it had been double locked over the years, but it was not stored in a separately locked compartment at the time of observation.
Failure to Thoroughly Investigate Bruising of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate the possibility of abuse for a resident who was found with multiple bruises of unknown origin. The resident, who had severe cognitive impairment and was on blood thinning medication, was discovered by a CNA to have several bruises on her arms, calves, and behind her knees during a shower. The incident was reported to the RN, who assessed the resident, notified the DON, the resident's power of attorney, and the physician, and obtained statements from staff and interviewed other residents. However, the investigation did not include skin checks for non-interviewable residents to rule out abuse, nor did it explore all possible causes for the bruising, such as the use of compression stockings or recent behavioral incidents. The facility's investigation focused primarily on the resident's elevated INR and the possibility of bruising from sitting on hard surfaces, despite the presence of a cushion on the dining chair and no assessment of other potential sources like the toilet or shower chair. Additionally, a progress note indicated the resident had hit staff during toileting, but this was not investigated as a possible cause for the arm bruising. The DON concluded the investigation after attributing the bruising to the high INR, without further exploration of other plausible causes or a comprehensive assessment of the situation.
Failure to Prevent and Address Resident Bruising Due to Inadequate Supervision and Hazard Mitigation
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision or interventions to prevent accidents for a resident with multiple medical conditions, including dementia, atrial fibrillation, and use of blood thinners. The resident, who had severe cognitive impairment and required supervision or assistance with transfers, toileting, and eating, was found with multiple bruises on her arms and legs after a shower. The facility's assessment did not determine the root cause of the arm bruises, and there was no documentation or evidence that interventions were added to the care plan to prevent recurrence. Possible causes such as rolling up compression stockings, hard toilet and shower chair surfaces, and the resident's combativeness during care were identified but not addressed through new interventions or care plan updates. Additionally, the facility did not provide education to staff on ways to prevent injury or recurring bruises following the incident, despite documentation indicating that education was completed. Staff statements and interviews revealed a lack of follow-up on potential causes and no new measures to protect the resident's skin or mitigate combativeness during care. The facility's records and critical event forms did not reflect any assessment or intervention to address the identified hazards, resulting in a failure to prevent further injury and ensure the resident's environment was as free from accident hazards as possible.
Failure to Notify Law Enforcement of Resident-to-Resident Abuse
Penalty
Summary
An incident occurred in which one resident with severe cognitive impairment struck another resident, also with severe cognitive impairment, in the upper right arm with a closed fist after a verbal exchange. The facility's policy requires immediate reporting of all suspected crimes, including alleged abuse, to local law enforcement. While the facility did report the incident to the state agency, notified both residents' power of attorney, and conducted an internal investigation, there was no evidence that local law enforcement was notified as required by facility policy. During interviews, the Director of Nursing stated that they did not believe the situation required law enforcement involvement, as the strike was considered soft and did not result in injury. However, the facility's policy does not make exceptions based on the perceived severity of the incident or the presence of injury. The failure to notify law enforcement of the potential crime of assault constituted a deficiency in following established abuse reporting protocols.
Incomplete Investigation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation following a resident-to-resident physical altercation involving two residents, both of whom had severe cognitive impairment as indicated by low BIMS scores and diagnoses including Alzheimer's, dementia, and other chronic conditions. The incident occurred when one resident struck another in the upper right arm with a closed fist after a verbal exchange in a common area. Staff intervened before the situation escalated further, and both residents were subsequently separated and assisted by staff. Despite facility policy requiring immediate examination, assessment, and interviews with the involved and potentially affected residents, the investigation did not include interviews with other residents to determine if they had also been targeted or affected by the incident. The Director of Nursing acknowledged that no additional resident interviews were conducted at the time, based on the belief that the event was isolated, even though both residents had access to others in the facility. The deficiency centers on the incomplete investigation process and lack of resident interviews beyond those directly involved in the altercation.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the resident environment remained as free from accident hazards as possible by not updating a resident's care plan after each fall event. Specifically, a resident with Alzheimer's, chronic kidney disease, dementia, difficulty walking, unsteadiness on feet, and severe cognitive impairment experienced an increase in fall risk score and multiple falls, including one resulting in a bruise and pain on the left foot. Despite these incidents and an increase in the resident's fall risk score, the care plan was not updated to reflect new interventions or strategies to prevent further falls. Facility policy requires that after a fall, the licensed nurse must fill out a care plan update sheet with new interventions, and the management team must review the incident to ensure interventions are new, appropriate, and documented. However, after the resident's fall risk increased and after subsequent falls, the care plan remained unchanged except for the addition of a bed alarm. Interviews with the DON confirmed that no new interventions were added, and the care plan continued to indicate only that the resident was likely to try and ambulate, without further updates to address the increased risk.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. A dietary aide heated a resident's lunch in the microwave but did not check the food's temperature to ensure it was safe for consumption. The dietary aide admitted to routinely heating the food for a set time without verifying the temperature, despite acknowledging that checking the temperature would be sensible for resident safety. The dietary manager confirmed that there was no established system for ensuring food was heated to safe temperatures. Additionally, during an inspection of the facility's kitchen, several issues were noted. Uncooked hotdogs and canned cranberries were found in the cooler without proper labeling of expiration or discard dates. A container of breadcrumbs was also found unlabeled and undated. Furthermore, the deep fryer was not cleaned after use, with leftover food debris present. The dietary manager acknowledged these oversights, stating that the items should have been labeled and discarded appropriately, and the fryer should have been cleaned immediately after use.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS from January 1, 2024, to September 30, 2024, was complete, accurate, and auditable. The Payroll Based Journal (PBJ) Staffing Data Reports indicated that there were no registered nurse (RN) hours recorded on specific dates and that the facility failed to maintain licensed nursing coverage 24 hours a day on several occasions. Upon review, it was found that the Director of Nursing and the MDS Coordinator, both registered nurses, covered the RN shifts but were not coded as such in the PBJ data. This oversight led to the inaccurate reporting of staffing data, affecting all 19 residents in the facility. The surveyor's review of daily postings, including nursing schedules and pay stubs, did not reveal any actual lapses in 24-hour nursing coverage or RN coverage for at least 8 hours. However, the failure to accurately code the RN coverage in the PBJ data resulted in the deficiency. The Administrator Assistant acknowledged the error and indicated that more manual submissions might be necessary to ensure accurate reporting in the future.
Inadequate Infection Control Program and Precautions
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, which led to several deficiencies affecting both residents and staff. The facility lacked a clear water management process to prevent Legionella infection, as evidenced by the absence of a flow diagram and updated Water Management Plan (WMP) with identified high-risk areas. The surveyor noted that there were no documented weekly flushes for unoccupied rooms, and the Assistant Director of Nursing (ADON) and Nursing Home Administrator (NHA) were unaware of these omissions. The facility's infection control surveillance logs were incomplete, missing critical information such as symptom onset, testing, and precautionary measures. The ADON, who also serves as the Infection Preventionist, admitted to not tracking necessary data throughout the year, resulting in inconsistent and incomplete line lists. This lack of documentation hindered the early detection and management of infections among residents and staff. Additionally, the facility failed to implement appropriate Transmission-Based Precautions for a resident with pneumonia and a fever. Staff members were observed not wearing masks when providing care, and the resident was not placed on droplet precautions in a timely manner. Furthermore, the facility's process for handling infectious linens was inadequate, with soiled linens not being properly identified or handled with appropriate personal protective equipment (PPE). The ADON acknowledged the need for a revised policy on handling infectious linens.
Lack of Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident on anticoagulant therapy, specifically Warfarin, which is used to manage atrial fibrillation. The resident, who has diagnoses including unspecified dementia, chronic atrial fibrillation, and essential hypertension, was admitted to the facility and had been using an anticoagulant daily for the last seven days as confirmed by the Minimum Data Set assessment. Despite this, the resident's care plan did not include a specific plan addressing the anticoagulant use and associated bleeding risk. Interviews with the resident's Power of Attorney, a Registered Nurse, and the Assistant Director of Nursing revealed concerns and gaps in the facility's approach to managing the resident's bleeding risk. The Power of Attorney expressed concern about the resident's care related to anticoagulant therapy. The Registered Nurse indicated that while skin assessments for bleeding issues were conducted, there was no formal documentation in the Electronic Health Record. The Assistant Director of Nursing confirmed that the resident did not have a care plan for bleeding risk and acknowledged that staff had no formal guidance to monitor for bleeding risk, relying instead on general expectations for monitoring.
Failure to Prevent and Manage Pressure Injury
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the development of a pressure injury for a resident who was admitted without skin impairments. The resident, who was completely dependent on caregivers for all activities of daily living and mobility, developed a stage 2 pressure injury to the coccyx area, which remained unhealed due to a lack of timely care plan interventions and repositioning. The resident's admission Minimum Data Set (MDS) assessment identified them as at risk for pressure injuries, yet no turning/repositioning program or nutrition/hydration program was documented. Observations revealed that the resident was often left in the same position for extended periods, with inadequate offloading of pressure from bony prominences. The resident's Braden score indicated a high risk for developing pressure injuries, yet the care plan did not address skin integrity concerns or pressure injuries until much later. The resident was observed to have an open area on the left buttock, which was not properly managed, as evidenced by inappropriate cleansing techniques that caused bleeding and pain. Interviews with staff indicated a lack of consistent and effective interventions to manage the resident's pressure injury. The Assistant Director of Nursing acknowledged that the care plan should have been updated immediately when the pressure injury was identified. Despite the resident's high risk and existing pressure injury, the facility failed to implement a comprehensive care plan and consistent repositioning schedule, contributing to the resident's ongoing skin integrity issues.
Inadequate Supervision and Assistance for At-Risk Residents
Penalty
Summary
The facility failed to ensure resident safety by not providing adequate supervision and assistance to residents identified as fall risks. Resident 12, who has a history of falls and moderate cognitive impairment, was observed ambulating alone multiple times without the required contact guard assist, despite being assessed as needing assistance during ambulation. The Assistant Director of Nursing (ADON) confirmed that the resident should not be ambulating alone and that staff should be present to assist. Similarly, Resident 16, who also has moderate cognitive impairment and requires assistance during transfers, was observed self-transferring and ambulating without staff assistance. An alarm was triggered when the resident transferred from a wheelchair to a recliner, but staff response was delayed. The ADON acknowledged that the care plan was not updated with necessary interventions following a previous fall, and staff were not aware of the required assistance level for the resident. Resident 15, identified as a choking hazard due to severe cognitive impairment and post-stroke symptoms, was left unsupervised during meals. The resident was observed eating alone in the dining room and later in their room without staff supervision, contrary to the care plan that requires monitoring during meals. The ADON confirmed that the resident should always be supervised while eating to prevent choking incidents.
Inappropriate Catheter Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident with an indwelling Foley catheter received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections. The resident, who was admitted with diagnoses including benign prostatic hyperplasia and other urinary conditions, had an order for the catheter to be changed every four weeks. This routine change was not based on clinical indications such as infection or obstruction, which is contrary to the guidelines suggested by the Centers for Disease Control and Prevention (CDC). During the survey, the Assistant Director of Nursing (ADON) was unable to provide a physician's reason for the monthly catheter change and acknowledged awareness of the current standard of practice, which was not being followed in this case. The ADON indicated that most residents were following the standard, but no documentation was provided to justify the deviation in this resident's care. This lack of adherence to professional standards of practice was identified as a deficiency by the surveyors.
Failure to Address PTSD and Provide Social Services
Penalty
Summary
The facility failed to provide medically related social services to address the needs of a resident diagnosed with Post Traumatic Stress Disorder (PTSD), generalized anxiety disorder, major depressive disorder, sleep disturbance, psychophysiological insomnia, and agoraphobia disorder. The resident, who was admitted with these diagnoses, had a Minimum Data Set (MDS) assessment indicating intact cognition and a Patient Health Questionnaire (PHQ)-9 score reflecting moderate depression. Despite these indicators, the resident's care plan lacked a specific plan addressing PTSD, and there were no documented non-pharmacological interventions to help the resident cope with PTSD and anxiety. The resident expressed dissatisfaction with the emotional support provided, noting that the facility lacked a dedicated social worker and that staff often suggested medication as the primary solution for anxiety. Observations by the surveyor revealed the resident frequently remained in bed, appeared depressed, and expressed a desire to leave the facility. Interviews with facility staff, including the Social Worker/Health Unit Clerk and the Assistant Director of Nursing, confirmed the absence of a PTSD care plan and behavior monitoring for the resident. Additionally, there was no documentation of any sessions or interventions in the resident's Electronic Medical Record (EHR), highlighting a significant gap in the provision of necessary social services for the resident's well-being.
Lack of Communication Binder for Hospice Services
Penalty
Summary
The facility failed to ensure a proper communication process between the long-term care (LTC) facility and the hospice provider, which is necessary to address and meet the needs of a resident 24 hours per day. Specifically, the facility did not have a communication binder for hospice services to relay information regarding hospice care for one resident (R2) investigated for hospice services. During a record review, the surveyor could not find any communication with hospice besides notes documented by facility staff members. When asked, the Assistant Director of Nursing (ADON) admitted they could not locate the communication binder for R2, which is typically used as the main way to communicate with hospice. The hospice provider does not have access to the facility's Electronic Medical Record, and the facility usually maintains binders for all residents on hospice, but the binder for R2 was missing.
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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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