Good Shepherd Services Ltd
Inspection history, citations, penalties and survey trends for this long-term care facility in Seymour, Wisconsin.
- Location
- 607 Bronson Rd, Seymour, Wisconsin 54165
- CMS Provider Number
- 525509
- Inspections on file
- 17
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Good Shepherd Services Ltd during CMS and state inspections, most recent first.
A resident with Lewy Body dementia, severe cognitive impairment, and an activated POA for healthcare told a CNA during morning care that they had been raped two days earlier, and repeated the allegation later that morning in front of the AD and DON. The CNA reported the allegation to an LPN and the DON, and the ED was informed during a behavior meeting, but neither law enforcement nor the State Agency were notified, despite facility policy requiring immediate reporting of all abuse allegations to the SA and, as applicable, to outside authorities such as law enforcement and APS.
A resident with Lewy Body dementia, severe cognitive impairment, and an activated POA for healthcare reported to a CNA, the AD, and the DON that the resident had been raped. Although facility policy requires a thorough abuse investigation, including evidence collection, interviews with the alleged victim, other residents, and staff, and possible involvement of law enforcement, the facility did not complete these steps. The DON acknowledged hearing the allegation and performing a skin assessment but confirmed that law enforcement was not notified and that additional staff or resident interviews were not conducted. The ED confirmed that a sexual assault exam was not offered and that staff education on reporting and investigation requirements was not completed.
The facility failed to prevent physical abuse when a cognitively impaired resident with dementia and anxiety disorder twice assaulted other severely cognitively impaired residents. In one incident, an LPN observed the aggressive resident arguing with another resident and forcefully squeezing that resident's wrist, resulting in bruising to the victim's hand and wrist and a bruise and skin tear to the aggressor's hand. In a separate incident, staff saw the same resident extend a leg to trip a wheelchair-bound resident and forcibly grab that resident's hand and wrist, causing pain and two bruises. Both victims had dementia with severely impaired cognition, and staff documentation and interviews confirmed the resident-to-resident altercations and resulting injuries.
A resident with intact cognition and medical conditions including DM2 and rheumatoid arthritis reported, along with their responsible party, that cash and gift cards were missing from the resident’s walker. An agency CNA admitted to taking the money and gift cards. Facility policy requires training and procedures to prevent abuse, neglect, and misappropriation, but the ED reported that while background checks and credential verifications are done for agency staff, the facility does not provide or require documentation of abuse, neglect, and misappropriation training for agency personnel and continues to use agency staff without such training documentation.
The facility did not maintain a complete infection prevention and control program, with missing documentation for Legionella prevention, outdated infection control policies, and failure to update procedures for communicable diseases and vaccinations. Staff did not consistently implement enhanced barrier precautions for residents with wounds or non-intact skin, as two CNAs provided high-contact care to a resident on EBP without PPE, and another resident with a reopened wound was not placed on EBP until several days after the wound was identified.
Three residents were prescribed psychotropic medications, including those with black box warnings, without proper documentation of informed consent from themselves or their legal representatives. Required consent forms were either missing, incomplete, or not properly signed and dated, despite facility policy mandating thorough review and documentation of consent for such medications.
Two residents who were hospitalized did not receive the required written transfer and bed-hold notices, nor were their transfers properly reported to the Ombudsman. One resident, who was cognitively intact, was transferred to the ED without written notification, and staff later admitted to shredding the forms. Another resident with moderate cognitive impairment and a POA for healthcare was transferred for cellulitis, but only received verbal notification, with no written notice provided to the resident or representative. The Ombudsman was not notified in either case, and staff interviews revealed inconsistent practices regarding these regulatory requirements.
A resident with multiple chronic conditions and moderately impaired cognition experienced a reopened chronic wound and was placed on enhanced barrier precautions (EBP). Despite new physician orders for wound care and the initiation of EBP, the care plan was not updated to reflect these changes. Staff confirmed the care plan omissions, and the DON acknowledged that necessary interventions and precautions were not added.
Two residents with severe cognitive impairment and high fall risk experienced multiple falls, but their care plans were not updated with new interventions after each incident as required by facility policy. Additionally, a fall mat intervention was not consistently implemented for one resident, with the mat found under the bed instead of beside it. Staff and medical record reviews confirmed that the process for revising care plans post-fall was not followed.
A resident with COPD and chronic respiratory failure, who required continuous oxygen therapy, was observed with a nasal cannula connected to a portable oxygen tank that was not turned on, resulting in an oxygen saturation of 69%. An LPN confirmed the oxygen should have been set at 2 LPM, and after adjustment, the resident's saturation improved to 97%. The facility lacked an oxygen use policy, and staff did not follow the physician's order for continuous oxygen.
The QAA committee did not consistently include the required members, as the DON/IP was absent from two quarterly meetings, resulting in incomplete committee attendance for quality assessment and assurance activities affecting all residents.
A resident with severe cognitive impairment and a history of infections was observed with their catheter drainage bag in direct contact with a floor mat without a protective barrier. Staff interviews confirmed that the facility's practice was to use covers for catheter bags and to keep them off the floor, which was not followed in this instance.
Failure to Report Allegation of Sexual Abuse to Law Enforcement and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to local law enforcement and the State Agency as required by its own policy and by section 1150B of the Act. On 4/15/26, a resident with Lewy Body dementia, psychotic/mood disturbance, depression, severe cognitive impairment (BIMS score 6/15), and an activated POA for healthcare told a CNA during morning cares that they had been raped two days earlier. The CNA ensured the resident’s safety and immediately reported the allegation to an LPN and the DON. Later that morning, the resident again stated they had been raped in the presence of the Activities Director and the DON, and the DON acknowledged hearing these statements in a common area. Despite multiple staff being aware of the allegation, no report was made to local law enforcement or the State Agency. The LPN stated they did not take further action because the DON was already aware. The DON confirmed that the incident was not reported externally, even though the facility’s abuse investigation policy requires all allegations of abuse to be sent immediately to the Division of Quality Assurance and indicates that investigations are to include notification to outside authorities such as law enforcement and APS as applicable. The Executive Director reported being informed of the allegation during a behavior meeting later that morning and verified that the allegation was not reported to law enforcement or the State Agency due to concerns about the resident’s potential psychological distress from an investigation, police involvement, or hospitalization, even though the facility typically reports such allegations.
Failure to Thoroughly Investigate Resident’s Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly and accurately investigate an allegation of sexual abuse made by one resident. On 4/15/26, during morning cares at approximately 7:00 AM, the resident told a CNA that the resident had been raped two days earlier. The CNA ensured the resident was safe and immediately reported the allegation to an LPN and the DON. Later that morning, the resident again stated that the resident had been raped to the Activities Director and the DON while in a common area. The resident’s medical record showed diagnoses including Lewy Body dementia with psychotic/mood disturbance and depression, and a BIMS score of 6/15 indicating severely impaired cognition, with an activated POA for healthcare. Despite the facility’s written policy requiring a thorough investigation of abuse allegations, including collecting and preserving physical evidence, interviewing the alleged victim and witnesses, interviewing other residents and staff, and involving regulatory authorities such as law enforcement, these steps were not carried out. The DON confirmed hearing the resident’s rape allegation and reported completing a skin assessment and updating the care plan, but did not recall staff interviews being conducted and verified that law enforcement was not notified. The Executive Director confirmed that no additional staff or resident interviews were completed and that a sexual assault exam was not offered to the resident or the resident’s POA. The Executive Director also confirmed that staff education related to reporting and investigating requirements was not completed, demonstrating that the facility did not follow its own policy for a thorough and accurate investigation of the abuse allegation.
Failure to Prevent Resident-to-Resident Physical Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect three residents from physical abuse by another resident. One resident (R1), admitted with dementia and anxiety disorder and assessed with a BIMS score of 3/15 indicating severely impaired cognition, physically assaulted two other cognitively impaired residents. Another resident (R2), admitted with Alzheimer's disease and dementia and assessed with a BIMS score of 0/15, was observed during a facility-reported incident on 12/4/25 at approximately 5:30 PM in an argument with R1 at the end of the hallway. Staff, including an LPN, witnessed R1 holding and aggressively squeezing R2's right wrist. R2 was noted to have bruising on the right hand and wrist, and R1 later was documented to have a reddish-purple bruise and a skin tear on the top of the left hand. Both residents were unable to provide an account of the incident, and R1 believed R2 was trespassing in R1's room. In a separate facility-reported incident on 12/9/25, R1 targeted another resident, R4, who was also admitted with dementia and anxiety disorder and had a BIMS score of 0/15, indicating severely impaired cognition. Staff observed R1 stick a leg out in front of R4's wheelchair as if to trip R4, then become aggressive, grab R4's right hand/wrist, and refuse to let go. R4 called out, stating that R1 was hurting them, and was later documented to have two bruises on the right hand. An RN progress note and staff interviews confirmed that R1 attempted to trip R4 and grabbed R4's right hand, causing pain and visible bruising. These incidents demonstrate that the facility did not prevent resident-to-resident physical abuse involving vulnerable, cognitively impaired residents.
Failure to Prevent Misappropriation of Resident Property by Agency CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when an agency CNA took cash and gift cards from the resident’s belongings. The resident, who had type 2 diabetes and rheumatoid arthritis and was cognitively intact with a BIMS score of 15/15, reported with their responsible party that $276.00, a McDonald’s gift card, and a Starbucks gift card were missing from the resident’s walker. The incident was reported to staff in the morning, and the missing items were identified by the resident and the resident’s child as having been stored on the walker. The facility’s abuse, neglect, and misappropriation policy requires that residents not be subjected to abuse or misappropriation by anyone, and that staff receive training in interventions, reporting, detection, and what constitutes abuse, neglect, and misappropriation, as well as implementation of procedures to identify, correct, and intervene in situations likely to result in misappropriation. Despite this, the Executive Director stated that while the facility conducts background checks, TB tests, and verifies licenses, COVID-19 vaccination, and CPR certification for agency staff, it does not require or provide abuse, neglect, and misappropriation training for agency staff and relies on the staffing agency to ensure such training. The Executive Director also stated the facility continues to use agency staff without requiring documentation of abuse, neglect, and misappropriation training from the agency. An agency CNA admitted to taking the resident’s money and gift cards, and later returned the gift cards and an amount of cash that did not match the amount reported missing.
Inadequate Infection Control Program and Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, as evidenced by incomplete policies, lack of required documentation, and improper implementation of enhanced barrier precautions (EBP). The facility's Legionella Policy and Procedure for Water Management did not include a detailed flow diagram of the water system, and the Maintenance Director was unable to provide such a diagram or specific corrective actions for situations when Legionella control measures were not met. Additionally, infection control policies were not reviewed or updated annually, and several policies lacked current information, such as updates on pneumococcal and influenza vaccines, procedures for staff who refuse vaccinations, and a comprehensive list of communicable diseases that must be reported to the health department. Staff failed to implement EBP as required for residents with wounds or non-intact skin. One resident, who had a percutaneous endoscopic gastrostomy (PEG) tube removed and was on EBP due to open skin, was observed receiving high-contact care, including linen changes and shaving, from two CNAs who did not wear personal protective equipment (PPE). The CNAs were unclear about when PPE was required, and one CNA stated that PPE was only necessary when in direct contact with the wound dressing, despite the resident being on EBP for a wound. The Director of Nursing confirmed that PPE should have been used during these high-risk tasks. Another resident with a chronic wound that reopened was not placed on EBP until three days after the wound was identified. During this period, staff were observed providing care without PPE, and there was no EBP signage or PPE cart outside the resident's room. The Director of Nursing verified that EBP should have been implemented immediately when the wound reopened, but this did not occur until several days later.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents or their legal representatives were fully informed and provided written consent prior to the administration of psychotropic medications. For one resident with intact cognition and a diagnosis of anxiety and muscle spasms, there was no documented consent for the prescribed diazepam, a medication with a black box warning. For another resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), consent forms for lorazepam, bupropion, and duloxetine were not properly initialed, dated, or signed by the POAHC after the expiration of verbal consent. A third resident, who had severe cognitive impairment and an activated POAHC, was prescribed olanzapine, also with a black box warning, without a completed informed consent form in the medical record. The facility's policy required that residents or their responsible parties be informed of the reasons for psychotropic medication orders, possible side effects, and alternative methods, and that written consent be obtained and documented. Staff interviews confirmed that the required consent forms were either missing, incomplete, or not properly reviewed and signed, resulting in a lack of documented informed consent for the use of psychotropic medications for these residents.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written notifications and documentation regarding transfer, bed-hold policies, and appeal rights for two residents who were hospitalized. One resident, who was cognitively intact and responsible for their own healthcare decisions, was transferred to the emergency department due to a toe injury but did not receive a written transfer or bed hold notice. The facility also did not notify the Ombudsman of this transfer. Staff interviews revealed confusion about when to complete and provide these notices, with one nurse admitting to shredding the forms under the mistaken belief that they were only necessary for hospital admissions, not transfers. Another resident, who had moderate cognitive impairment and an activated Power of Attorney for Healthcare, was transferred to the hospital for cellulitis. The medical record indicated only verbal notification was provided, with no evidence that a written transfer or bed hold notice was given or mailed to the resident or their representative. Additionally, the Ombudsman was not notified of this transfer. Staff interviews confirmed inconsistent practices regarding the provision and documentation of these notices, and the facility's discharge notifications to the Ombudsman did not include residents transferred with a bed hold, contrary to regulatory requirements.
Failure to Revise Care Plan After Wound Reopened and Enhanced Barrier Precautions Initiated
Penalty
Summary
The facility failed to revise the care plan for a resident after a chronic wound reopened and after the resident was placed on enhanced barrier precautions (EBP). The resident, who had diagnoses including chronic diastolic heart failure, metabolic encephalopathy, and chronic kidney disease, was admitted with moderately impaired cognition and had an activated Power of Attorney for Healthcare. The care plan, dated prior to the wound reopening, did not reflect the presence of the wound or the implementation of EBP. Progress notes documented that the wound reopened and that new physician orders were obtained for wound care, but these changes were not incorporated into the resident's care plan. Staff interviews confirmed that the care plan was not updated to include the reopened wound or the initiation of EBP. The Director of Nursing acknowledged that wound interventions and precautions should have been added to the care plan when the wound reopened. Additionally, the Nursing Home Administrator indicated that the facility did not have a care plan policy in place.
Failure to Update Fall Interventions and Implement Safety Measures
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents for two residents with severe cognitive impairment and high fall risk. Both residents had multiple falls within a short period, and their care plans were not updated with new interventions following each incident, despite facility policy requiring such updates. For one resident, the care plan included the use of a fall mat when in bed, but this intervention was not consistently implemented, as the fall mat was observed under the bed rather than beside it on at least one occasion. Medical records and staff interviews confirmed that after each fall, no new interventions were added to the care plans of either resident, and the process for updating care plans post-fall was not followed. Both residents had significant cognitive deficits and mobility issues, further increasing their risk for falls. The facility's own fall policy required that a new intervention be added to the care plan after each fall, but this was not done, and required safety equipment was not always in place as specified.
Failure to Provide Ordered Continuous Oxygen Therapy
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia, who had severe cognitive impairment and an activated Power of Attorney, was admitted with a physician's order for continuous oxygen at no more than 3 liters per minute (LPM) to maintain oxygen saturation at 90% or above. During observation, the resident was seen in a wheelchair with a nasal cannula connected to a portable oxygen tank that was not turned on, and the tank was set at 0. Upon verification by an LPN, it was confirmed that the oxygen should have been set at 2 LPM continuously, and that CNAs were responsible for turning on the oxygen tank unless an adjustment was needed. The resident's oxygen saturation was measured at 69% before the oxygen was turned on and increased to 97% after the oxygen was set to 2 LPM. Further review revealed that the facility did not have an oxygen use policy in place, as confirmed by the Director of Nursing. The resident's medical record included orders for continuous oxygen and regular checks and changes of oxygen tubing, but these were not followed at the time of the surveyor's observation. The failure to ensure the resident's oxygen was administered as ordered constituted a deficiency in providing necessary respiratory care and services.
QAA Committee Lacked Required Members at Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the minimum required members and met at least quarterly as required. Review of QAA committee meeting sign-in sheets for the past four quarters showed that the committee met on four occasions; however, the Director of Nursing (DON), who also served as the Infection Preventionist (IP), was absent from two of these meetings. This absence was confirmed by both documentation and staff interview with the Nursing Home Administrator (NHA), who verified that the DON/IP did not attend the meetings in question. As a result, the QAA committee did not meet with all required members for two of the four reviewed quarters, affecting the oversight of quality assessment and assurance processes for all 31 residents in the facility.
Inappropriate Care for Resident with Indwelling Catheter
Penalty
Summary
The facility did not provide appropriate care and services for a resident with an indwelling catheter. On 4/10/24, a surveyor observed the resident's catheter drainage bag in direct contact with a floor mat without a barrier to prevent infection. The facility's policy on the nursing care of an indwelling urinary catheter did not include a process to prevent catheter drainage bag exposure to potentially infectious settings. The resident, who had severe cognitive impairment and a history of infections, was found asleep in bed with the catheter bag resting on the floor mat next to the foot of the bed. Interviews with staff revealed that the facility's practice was to use a cover for catheter drainage bags and to ensure that uncovered bags were not in contact with the floor. A CNA and an RN both confirmed that catheter bags should not be on the floor and should contain a cloth cover for infection control and dignity. The Nursing Home Administrator also stated that staff were expected to keep catheter bags covered and off the floor.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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