Greendale Park Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Greendale, Wisconsin.
- Location
- 5404 W Loomis Rd, Greendale, Wisconsin 53129
- CMS Provider Number
- 525549
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Greendale Park Nursing And Rehab during CMS and state inspections, most recent first.
An incident of physical abuse between two residents was not reported to the state survey agency within the required two-hour timeframe. An LPN witnessed the altercation and notified the DON, who then contacted the ADM. Due to misunderstanding of the reporting policy, the ADM submitted the report the next day instead of immediately as required.
The facility did not complete a thorough investigation into an incident of resident-to-resident abuse, failing to interview or document statements from witnesses, including two residents and staff who observed the event. Despite policy requirements to interview all involved and maintain complete records, key witness accounts were missing from the investigation documentation.
A required discharge MDS assessment was not completed or transmitted for a resident who was transferred to the hospital and did not return. Review of the electronic health record and staff interviews confirmed the omission, with the MDS coordinator unable to provide a reason for the oversight. Both the DON and NHA were notified of the missing assessment.
A resident with a G-tube did not receive enteral feeding according to physician orders, as the feeding continued during scheduled off times and staff were unclear about the feeding schedule. Additionally, there were no documented interventions or orders for monitoring or caring for the G-tube site, despite facility policy requiring such care. The resident, who was nonverbal and dependent on staff, was observed with leaking tube feeding and lacked appropriate site monitoring and documentation.
A resident was transferred or discharged without adequate preparation to ensure their needs and preferences were met, resulting in a failure to provide a safe and individualized transition.
Two residents were transferred to the hospital on multiple occasions without receiving the required written transfer and bed-hold notices, which should have included details such as the reason for transfer, bed-hold duration, appeal rights, and ombudsman contact information. Review of records and staff interviews revealed that the facility did not consistently provide or document these notices, and staff were unclear about who was responsible for this process.
Two residents with significant cognitive and physical impairments did not have comprehensive, person-centered care plans addressing urinary incontinence, including measurable objectives and timeframes. Although staff reported providing incontinence care every two hours or as needed, this frequency was not documented in the care plans or CNA Kardex, and documentation of care provided was inconsistent. Nursing staff and management acknowledged that care plans lacked specific instructions, resulting in a deficiency in meeting regulatory and facility policy requirements.
A medication error rate above 5% was identified when an LPN failed to prime both Humalog and Glargine insulin pens before administration and did not date the Glargine pen upon opening, as observed during a medication pass for a resident. Interviews confirmed that facility policy requires priming and dating of insulin pens, but the LPN was unaware of the correct procedure.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with multiple comorbidities and incontinence was admitted with several stage 2 pressure injuries and MASD. The facility failed to conduct timely skin assessments and did not implement appropriate wound treatments upon admission and readmission. No treatment was provided for several days, resulting in the development and worsening of a stage 3 pressure injury that required surgical debridement. An incontinence care plan was not implemented, and appropriate wound care was delayed until the resident was seen by a wound physician.
A resident with a history of diverticulosis and constipation did not receive appropriate bowel monitoring or interventions upon admission, despite being at risk due to medical history and opioid use. Documentation of bowel elimination was inconsistent, and staff failed to assess or address the resident's complaints of nausea and diarrhea. After a hospital visit revealed significant stool burden, recommended medication changes were not implemented, and a care plan for constipation risk was not initiated. Staff interviews revealed gaps in communication and documentation, and the facility could not provide a bowel monitoring policy when requested.
A resident with severe cognitive impairment, total incontinence, and existing pressure injuries did not have an individualized incontinence care plan implemented, despite facility policy and clinical indications. The care plan and Kardex lacked specific interventions such as a check and change schedule, and staff interviews confirmed the absence of documented incontinence management, contributing to ongoing skin complications.
A resident at high risk for pressure injuries did not receive adequate care upon admission, leading to a facility-acquired pressure injury. The facility failed to conduct a comprehensive skin assessment and delayed implementing treatment orders. Inaccurate wound assessments and missed treatments further compromised the resident's care, despite interventions like heel boots and an air mattress.
A resident with multiple health issues experienced a fall from bed, found with an arm stuck in a bed rail, due to inadequate supervision and lack of a prior bed rail assessment. The facility failed to conduct a thorough investigation or reassess the appropriateness of the bed rails, leading to discrepancies in staff accounts and insufficient updates to the resident's care plan.
A resident with mobility impairments and cognitive intactness was found with bed rails installed without a prior risk assessment, contrary to facility policy. The resident's arm became entrapped in the bed rail, requiring emergency services. Staff interviews revealed that therapy assessments were not completed before bed rail installation, and the facility administration acknowledged the oversight without providing further information.
The facility's assessment was found lacking essential details on water management, infection prevention, and infectious disease management, potentially affecting all 76 residents. The DON acknowledged the omission during a surveyor's review and provided an updated assessment after being informed of the necessary components.
The facility failed to ensure RN coverage for at least eight consecutive hours daily on 17 days and did not designate a charge nurse for each shift. Staffing schedules lacked clarity on RN and agency staff roles, and the omission of charge nurse assignments was acknowledged as an error. Despite efforts to hire RNs and use agency staff, the facility struggled to maintain required coverage.
The facility failed to maintain an effective infection prevention and control program, with an outdated Water Management Plan lacking current standards and testing for Legionella. A resident's medication was handled barehanded by a nurse, breaching infection control practices. The facility's infection surveillance was inaccurate, missing a COVID-19 case, and the facility assessment lacked infection prevention information. Staff interviews revealed a lack of awareness and proper implementation of infection control measures.
The facility did not ensure that five CNAs completed the required annual 12 hours of educational training. CNA-C completed only 8 hours, and CNA-D completed only 7 hours in the last 12 months. This deficiency was identified through a record review and staff interview, with no explanation provided for the incomplete training.
A resident's medical record lacked a signed advance directive form for CPR, despite facility policy requiring this upon admission. The resident, with multiple health issues, had no care plan for advance directives, and the form was only completed after a surveyor's request. Interviews revealed the guardian had not signed the form, and there was no documentation of discussions about advance directives.
A facility failed to provide appropriate dialysis care for a resident, lacking physician orders, assessments, and a care plan for dialysis. The resident, with complex medical needs, did not have coordinated care with the dialysis center, and the facility's DON was initially unable to provide necessary information. The care plan was only updated after surveyor inquiry, indicating a deficiency in managing the resident's dialysis needs.
The facility failed to properly assess and obtain informed consent for bed rail use for two residents, with assessments not updated and consent not documented. Additionally, there was no routine maintenance schedule for bed rails, contrary to facility policy. These deficiencies were noted during surveyor interviews and observations.
The governing body of a facility failed to implement effective financial management policies, resulting in significant arrears with multiple vendors. This included essential services like pharmacy, food distribution, and medical equipment, threatening service disruptions. Interviews revealed a lack of awareness among staff about the financial issues, with responsibilities deferred to external consultants. The facility's financial instability could impact the care and safety of all residents.
A facility failed to prevent abuse by not implementing proper screening procedures for a CNA, who was later involved in an allegation of sexual assault against a resident. The CNA inaccurately completed a BID form, and the facility did not verify the DOJ background check or obtain references. This allowed the CNA to care for a resident who alleged sexual abuse, creating immediate jeopardy.
A resident did not receive a CBC and BMP as ordered due to a break in lab service from unpaid bills, which was not documented. The resident experienced multiple episodes of diarrhea, but the facility failed to assess the condition or obtain a stool sample to rule out infection. The resident was later diagnosed with dehydration, C-Diff, and a UTI at the hospital. The facility did not follow its incontinence policy, leading to a deficiency in care.
The facility failed to provide adequate pressure ulcer care and prevention for two residents at high risk for pressure injuries. One resident developed a stage 3 pressure injury and a DTI, while another developed a DTI, with care plans not revised to include necessary interventions. Initial assessments and treatments were delayed, and documentation was lacking, leading to deficiencies identified by surveyors.
The facility failed to provide required annual QAPI training to 4 out of 5 CNAs, as per their policy. The DON acknowledged a change in training software, which led to the inability to verify training completion. Only one CNA had completed the QAPI training, while the facility could not provide documentation for the others, potentially affecting all 69 residents.
A resident self-administered Entresto for heart failure without a proper assessment, physician's order, or care plan in place. The facility's policy requires an interdisciplinary team assessment and documentation for self-administration, which was not completed. The issue was identified, and the facility began administering the medication to the resident.
A resident's right to privacy was breached when their package was opened by an LPN without permission. The LPN was instructed by a receptionist to open the package, suspecting it contained knives, but it was actually medication. The facility's policy states that residents' mail should not be opened by staff, yet this incident occurred, leading to the resident's upset.
The facility failed to promptly investigate and resolve grievances for three residents during a survey. Despite having a grievance policy, the facility did not document or investigate grievances until prompted by the surveyor. Concerns about staff behavior and call light responses were not addressed, and documentation was incomplete, resulting in unresolved grievances.
The facility failed to report two incidents of alleged abuse involving residents to the State survey agency within the required timeframe. An allegation of sexual assault was not reported immediately, and a physical abuse allegation was reported two days late. The facility's policy requires timely reporting, but these incidents were not reported as mandated.
The facility failed to thoroughly investigate allegations of abuse, misappropriation, and neglect involving three residents. A resident with cognitive impairment reported a sexual assault, but not all staff on duty were interviewed. Another resident reported missing money and inappropriate behavior by a CNA, but the investigation lacked interviews with all relevant staff. A third resident alleged neglect, but staff were not questioned about their knowledge of the incident.
A resident did not receive documented showers over a month-long period, despite requiring substantial assistance for bathing. The facility's new system for tracking showers failed to ensure the resident's hygiene needs were met, as confirmed by staff interviews and lack of documentation.
A resident with hemiplegia and bilateral above-knee amputation did not receive adequate supervision and fall prevention interventions as outlined in their care plan. Despite the plan's directives, observations revealed the absence of a body pillow on the bed's right side and the call light not consistently within reach. The LPN confirmed these measures should have been in place, but no explanation was provided for the oversight.
A resident with Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Sleep Apnea did not receive appropriate respiratory care as the facility failed to document MD orders for CPAP settings and cleaning, and did not include CPAP use in the care plan. The LPN Unit Manager confirmed the need for such documentation, which was missing, and the issue was noted during a surveyor's investigation.
Two residents in the facility experienced significant medication errors due to unavailable medications. One resident, with a kidney transplant, missed six doses of Tacrolimus, while another, with heart failure, missed nine doses of Ivabradine. The facility's process for handling unavailable medications was inadequate, lacking clear policies on notifying providers and missing necessary medications in the contingency supply.
A resident with diabetes and bilateral above-knee amputations had inaccurate medical records indicating daily diabetic foot checks were performed, despite the absence of feet. The facility's MAR inaccurately documented these checks as completed, which was confirmed through a surveyor's review and staff interviews.
A resident with significant medical conditions complained of chest and rib pain. A Med Tech administered Tylenol but failed to alert a nurse, obtain vital signs, or determine pain level. The Med Tech did not follow up to verify medication effectiveness or notify the physician, contrary to facility policy.
A resident on Warfarin was not adequately monitored for side effects due to the lack of a specific care plan and monitoring orders. The facility's policy on managing anticoagulant therapy was not followed, leading to a deficiency identified by the surveyor.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the state survey agency within the required two-hour timeframe. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, an altercation occurred in which one resident hit another on the shoulder after being run into by a power wheelchair. The incident was witnessed by an LPN, who notified the Director of Nursing (DON) shortly after the event. The DON then contacted the Administrator (ADM), who was responsible for reporting abuse allegations to the state survey agency. Despite the policy requirements, the ADM submitted the abuse report to the state survey agency the following day, well beyond the two-hour window. Interviews revealed that both the DON and ADM were unclear about the correct reporting timeframe, with the DON believing the report was due within 24 hours and the ADM unaware that all abuse allegations required reporting within two hours, regardless of injury severity. Both residents involved had intact cognition and no behavioral symptoms documented during recent assessments.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident abuse involving two residents. According to facility policy, all involved persons, including witnesses, should be identified and interviewed, and complete documentation of the investigation should be maintained. However, the investigation did not include interviews or documentation from key witnesses who were present during the incident, such as two other residents and staff members who observed the altercation. The incident in question involved one resident hitting another on the shoulder, followed by a physical response. Both residents involved had intact cognition as indicated by their BIMS scores, and neither exhibited behavioral symptoms during their respective assessment periods. The event was reported promptly to the state survey agency, and staff separated the residents at the time of the incident. Despite this, the facility's investigative documents lacked statements or interviews from the witnesses who were present, including two residents with intact cognition and staff who directly observed the event. Interviews with facility staff revealed that the social services director and the director of nursing were unaware that other residents had witnessed the incident, and there was no documentation of interviews with the staff members who responded to the event. The administrator confirmed that all present during the incident should have been interviewed, but the investigation records did not reflect this. As a result, the facility did not meet its own policy requirements for a complete and thorough investigation of the abuse allegation.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge Minimum Data Set (MDS) assessment for one of two residents reviewed for MDS assessments and transmission. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records, including discharge assessments, to the Centers for Medicare and Medicaid Services' (CMS) Internet Quality Improvement Evaluation System (iQIES). The discharge assessment is to be completed no later than 14 calendar days after the discharge date. In this case, a resident was admitted to the facility and later transferred to the hospital, not returning to the facility. Upon review of the electronic health record, it was found that no discharge MDS assessment was completed or transmitted after the resident's discharge. During interviews, the MDS coordinator confirmed that a discharge MDS assessment is typically completed within seven days of a resident's discharge, but acknowledged that no such assessment was completed for this resident and was unsure why it was missed. The deficiency was confirmed through record review and staff interviews, with both the Director of Nursing and the Nursing Home Administrator being informed of the missing discharge MDS assessment. No additional information or explanation for the omission was provided by facility staff.
Failure to Follow G-Tube Feeding Orders and Provide Site Care
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube (G-tube) did not receive care and services in accordance with physician orders and facility policy. The resident had an order for enteral feeding with Jevity 1.5 at 65 mL/hour for 20 hours, to be stopped at 10:00 AM and restarted at 2:00 PM. However, multiple observations by the surveyor showed that the tube feeding continued to run during the period it was supposed to be off. Staff members, including CNAs and an LPN, were unclear about the feeding schedule, with some believing the feeding was continuous. The feeding was also observed to be leaking, resulting in formula on the resident's bed sheet. Further review revealed that there were no physician orders or documented interventions for monitoring, treatment, or care of the resident's G-tube site. The facility's policy required daily assessment and care of the G-tube site, including cleaning, monitoring for infection, and documentation of care provided. Interviews with staff, including the LPN, unit manager, and DON, confirmed that there were no orders or documentation for G-tube site monitoring or care on the resident's MAR/TAR or care plan. Staff were unsure about the expectations for G-tube care and could not locate relevant information in the resident's records. The resident in question had significant medical needs, including anoxic brain damage, chronic respiratory failure, protein-calorie malnutrition, and was dependent on staff for all activities of daily living. The resident was nonverbal, unable to follow commands, and at high risk for malnutrition. Despite these vulnerabilities, the facility failed to ensure that the resident's G-tube feeding was administered as ordered and that appropriate monitoring and care of the G-tube site were provided and documented.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation that indicated the resident's individual requirements and choices were not fully considered or addressed during the transfer/discharge planning process. As a result, the resident was not properly prepared for a safe transition, and the necessary steps to ensure their needs and preferences were met were not completed.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written transfer and bed-hold notices to two out of three residents reviewed who were hospitalized. Specifically, the facility did not issue documentation to the residents or their representatives that included the date and reason for transfer, location of transfer, duration of bed-hold, appeal rights, and contact information for the State Long-Term Care Ombudsman. This omission was identified through interviews and record reviews, which revealed that no such notices were found in the electronic health records (EHR) for the residents in question. One resident with diagnoses including muscle wasting, acute and chronic respiratory failure, and a tracheostomy was transferred to the hospital on three separate occasions. Progress notes documented the clinical events leading to each transfer, such as labored breathing, trach removal, and sepsis, but there was no evidence that the required transfer and bed-hold notices were provided or documented in the EHR. Another resident with multiple chronic conditions and an activated healthcare power of attorney was also transferred to the hospital, and again, no written notice was found in the EHR for this event. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for issuing transfer and bed-hold notices. The Nursing Home Administrator, Social Services Director, Admissions Director, RN Unit Manager, and Health Unit Coordinator each gave differing accounts of who was responsible for providing and documenting these notices. Some staff believed the notice was only required at admission or monthly, rather than at each transfer, and others were unaware of the requirement altogether. This lack of consistent process and documentation led to the deficiency.
Failure to Develop Comprehensive Incontinence Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address the urinary incontinence needs of two residents. For one resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living, the care plan lacked specific instructions regarding the frequency of incontinence care. Although staff interviews indicated that incontinence care was generally provided every two hours or as needed, this frequency was not documented in the resident's care plan or on the CNA Kardex. Additionally, documentation of incontinence care provided was inconsistent, with significant gaps in the electronic health record regarding the number and timing of urinations. For another resident with a history of stroke, diabetes, chronic respiratory failure, and moderate cognitive impairment, the care plan also failed to include a person-centered approach to incontinence care. The resident was assessed as always incontinent of urine and bowel and dependent on staff for all care. While the CNA Kardex and staff interviews indicated that incontinence care was provided every two hours or as needed, there was no specific care plan developed to address the resident's incontinence needs, nor was the frequency of care documented in the care plan or Kardex. Interviews with nursing staff and management confirmed that the facility's practice was to provide frequent check and change for incontinent residents, but this was not consistently reflected in the care plans. The lack of measurable objectives and timeframes in the care plans for both residents did not meet the facility's own policy requirements or regulatory expectations for comprehensive, person-centered care planning.
Medication Error Rate Exceeds 5% Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with a calculated error rate of 5.88% based on 2 errors in 34 observed opportunities. During medication administration, a Licensed Practical Nurse (LPN) did not prime a resident's Humalog insulin pen prior to dialing the prescribed dose, contrary to facility policy and procedure. The same LPN also failed to prime the resident's Glargine insulin pen before administration and did not ensure the insulin pen was dated when opened, as required for tracking expiration. These actions were directly observed by the surveyor during the medication pass. Interviews with the LPN and the Unit Manager confirmed that insulin pens should be primed with 2 units before each use and dated upon opening, with the Unit Manager stating that insulin expires 28 days after being opened. The LPN demonstrated a lack of knowledge regarding the priming procedure, stating incorrectly that priming was not necessary. The surveyor verified these deficiencies through direct observation, interviews, and review of facility policy, resulting in the identification of two medication errors for the resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple pressure injuries did not receive timely and appropriate assessment and treatment upon admission and readmission. The facility's own policies required a comprehensive skin assessment by a licensed or registered nurse upon admission and weekly thereafter, as well as prompt implementation of evidence-based wound treatments in accordance with physician orders. However, after the resident was admitted with several stage 2 pressure injuries and moisture-associated skin damage (MASD), no treatment was implemented for five days until the wound physician evaluated the resident. During this period, the resident developed a stage 3 pressure injury on the coccyx, which required surgical debridement. Upon the resident's readmission following hospitalization, the facility again failed to conduct a comprehensive assessment and did not implement appropriate treatments for the existing pressure injuries. The clinical admission note indicated that skin issues had not been evaluated, and the documentation and measurements were unchanged from the previous admission, despite the presence of a stage 3 pressure injury. Only a barrier cream was applied two days after readmission, which was not an appropriate treatment for a stage 3 pressure injury. It was not until five days after readmission, when the wound physician evaluated the resident, that the stage 3 pressure injury was found to have worsened and required further debridement. Throughout this period, the resident, who had significant medical comorbidities including severe hypoxic ischemic encephalopathy, chronic respiratory failure, and incontinence, did not have an incontinence care plan implemented. The lack of timely assessment, failure to initiate appropriate wound care, and absence of an incontinence care plan contributed to the progression and exacerbation of the resident's pressure injuries, as documented by both facility records and wound care specialists.
Failure to Provide Bowel Monitoring and Timely Interventions for Resident at Risk of Constipation
Penalty
Summary
A resident with a history of diverticulosis, constipation, and other significant medical conditions was admitted to the facility and did not have a care plan initiated for bowel monitoring or interventions, despite being at risk due to their medical history and opioid use. There was no documentation of bowel elimination until several days after admission, and the first recorded bowel movement was diarrhea, accompanied by complaints of nausea. The resident was not assessed or monitored for these symptoms, and there was no documentation regarding the nausea and diarrhea. Additionally, bowel elimination was not consistently documented every shift, and staff interviews revealed inconsistent practices and lack of communication regarding the resident's symptoms. The resident was later transferred to the hospital for evaluation of nausea and abdominal cramping, where a CT scan revealed moderate colonic stool burden and a mildly distended rectal vault, correlating with constipation. Upon readmission to the facility, hospital recommendations to increase laxative use and add MiraLAX were not implemented, and a care plan for constipation risk and bowel monitoring was still not initiated. Physician orders from the hospital were not promptly addressed, and staff interviews indicated a lack of awareness and follow-through regarding the resident's bowel status and related symptoms. Throughout the resident's stay, there was a lack of comprehensive assessment and documentation when the resident experienced gastrointestinal symptoms, such as nausea and diarrhea. Staff failed to consistently monitor, document, and communicate the resident's bowel status and related complaints, and did not implement or update care plans or interventions as required by professional standards of practice and the resident's needs. The facility also could not provide a bowel monitoring policy when requested by the surveyor.
Failure to Implement Incontinence Care Plan for Resident with Pressure Injuries
Penalty
Summary
A deficiency was identified when a resident who was always incontinent of bowel and bladder, and admitted with pressure injuries and Moisture Associated Skin Damage (MASD), did not have an individualized care plan implemented to manage incontinence. The facility's own policy required staff to assess, document, and manage incontinence, including the use of a check and change strategy to protect skin integrity, but this was not reflected in the resident's care plan or Kardex. The resident's records indicated total dependence for toileting hygiene and bed mobility, and the presence of a stage 3 pressure injury and MASD, yet there was no documentation specifying the frequency of incontinence checks or changes. Surveyor interviews with facility staff, including the Nurse Practitioner and the Acting Director of Nursing, confirmed that while the need for moisture management and skin care was communicated, there was no evidence of a specific incontinence care plan or schedule being implemented. The Nurse Practitioner noted that the MASD was likely due to a combination of incontinence-related wetness and shearing, and emphasized the importance of routine checking and changing. However, neither the care plan nor the Kardex included these interventions, and staff were unable to provide additional documentation or clarification during the survey. The lack of a personalized incontinence management plan for the resident, who was at high risk for skin breakdown and had existing pressure injuries, was directly observed and confirmed through record review and staff interviews. This omission was cited as a failure to provide appropriate treatment and services to prevent further skin-related complications, as required by facility policy and regulatory standards.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for a resident, identified as R8, who was at risk for developing such injuries. Upon admission, R8's skin was not assessed, and an individualized care plan was not developed based on R8's risks and care needs. The facility also delayed implementing treatment orders for R8's pressure injuries, which were documented in the hospital discharge paperwork. The contracted wound care provider's assessments incorrectly identified the location of the wounds, and the facility's wound assessments were not comprehensive. R8 was admitted with diagnoses including muscle wasting, epilepsy, dysphagia, dementia, and peripheral vascular disease. The hospital discharge paperwork noted unstageable pressure injuries on R8's left great toe and right heel, but the facility did not place treatment orders until several days after admission. The facility's care plan for R8 included interventions for altered skin integrity and pressure injury prevention, but these were not effectively implemented. R8's Braden Scale assessments indicated a high risk for developing pressure injuries, yet the facility's assessments were inconsistent and did not accurately reflect R8's condition. The facility's failure to conduct a comprehensive skin assessment upon admission and the delay in implementing treatment orders contributed to the development of a new facility-acquired pressure injury on R8's right great toe. Additionally, the facility's skin assessments were not completed according to current standards of practice, lacking detailed characteristics and measurements of the wounds. The facility also missed wound care treatments on specific dates, further compromising R8's care. Despite the presence of heel boots and an air mattress, R8 was observed with heels resting directly on the bed, indicating inadequate pressure relief measures.
Inadequate Supervision and Bed Rail Assessment Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent falls for a resident, identified as R8, who was found on the floor with his left arm stuck in a bed rail. The incident occurred without a prior bed rail assessment, which is a necessary step before applying bed rails to a resident's bed. The facility did not conduct a thorough investigation to determine the root cause of the fall, nor did they reassess the appropriateness of the bed rails for R8. Additionally, the care plan was not updated in a timely manner to include interventions that could prevent future falls. R8, a resident with multiple diagnoses including muscle wasting, epilepsy, and dementia, was admitted to the facility and assessed as dependent on staff for mobility and transfers. Despite being cognitively intact, R8 experienced a fall from bed, which was not witnessed by staff. The facility's fall investigation revealed discrepancies in the documentation of the incident, such as the position in which R8 was found and the fact that his arm was stuck in the bed rail, which was not initially mentioned in the investigation report. Interviews with staff, including the Director of Therapy and a Licensed Practical Nurse, highlighted a lack of communication and awareness regarding the incident. The Director of Therapy was unaware of the incident involving the bed rail, and the LPN provided conflicting accounts of the event. The facility's failure to conduct a comprehensive investigation and reassessment of the bed rail use, along with the discrepancies in staff statements, contributed to the deficiency in providing a safe environment for R8.
Failure to Assess Bed Rail Risks Leads to Resident Entrapment
Penalty
Summary
The facility failed to assess the risk of entrapment and review the risks and benefits of bed rail use for a resident, leading to a deficiency. The resident, who is dependent on staff for mobility and has a history of muscle wasting, epilepsy, and dementia, was observed with bed rails on both sides of the bed without a completed side rail risk assessment. The facility's policy requires a person-centered approach and a comprehensive assessment before bed rails are used, including evaluating alternatives and obtaining informed consent, which was not followed in this case. The resident's medical record indicated that on a specific date, the resident's left arm became stuck in the bed rail, necessitating emergency medical services. Despite this incident, a bedrail/mattress safety assessment was only completed the following day, determining the resident was safe to have assist bed rails. Observations by the surveyor on subsequent days found the resident unattended with bed rails still in place, and the resident confirmed the recent incident of entrapment. Interviews with facility staff revealed that therapy is responsible for assessing bed rail needs, but the assessment was not completed before the bed rails were applied. The Director of Therapy confirmed that an assessment should be completed prior to bed rail installation. The surveyor notified the facility's administration of the concerns regarding the lack of assessment before the bed rails were used, but no additional information was provided by the facility leadership.
Facility Assessment Lacks Critical Information
Penalty
Summary
The facility failed to ensure that the Facility Assessment was updated to include critical information regarding the water management committee, the infection preventionist, and infectious disease management. This oversight has the potential to affect all 76 residents residing in the facility. On October 3, 2024, a surveyor reviewed the Facility Assessment and found that it lacked details on water management, the infection preventionist, and infectious disease management. During an interview on October 7, 2024, the Director of Nursing (DON) acknowledged that the recent update to the Facility Assessment accidentally omitted this information. The surveyor informed the DON of the necessary components that should be included in the Facility Assessment. Later that day, the DON provided an updated copy of the Facility Assessment after the surveyor requested the missing information. The surveyor also communicated these concerns to the Assistant Director of Nursing and the Assistant Nursing Home Administrator.
Deficiency in RN Coverage and Charge Nurse Designation
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, on 17 out of 152 days reviewed. This deficiency was identified through a review of the Payroll Based Journal (PBJ) report and staffing schedules, which showed that the facility did not meet the required RN coverage on specific dates. The Scheduler acknowledged the issue, citing challenges such as staff call-ins and difficulties in hiring RNs, despite attempts to fill gaps with agency staff. The Director of Nursing (DON) and Administrator were aware of the low RN hours and were actively trying to hire additional RNs, but the facility still lacked adequate RN coverage on the noted days. Additionally, the facility did not designate a charge nurse for each shift, as the staffing schedules did not indicate which nurse was assigned this role. The Scheduler admitted that the schedules should reflect the RN and agency staff, and that the omission of charge nurse assignments was an error. The DON stated that staff typically knew who was in charge, as they carried a phone to signify their role, but no additional information was provided to explain why the charge nurse was not identified on the schedule.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which has the potential to affect all 76 residents. The Water Management Plan (WMP) was outdated and did not reflect current standards of practice. It lacked the inclusion of the Infection Preventionist (IP) and did not have current water testing for Legionella, with the last test conducted in June 2023. The facility's surveillance of the infection control program was also inaccurate, as it failed to include a resident who tested positive for COVID-19 in September. During the survey, it was observed that a nurse handled a resident's medication with bare hands during preparation, which is a breach of infection control practices. The facility's policy on infection prevention and control, implemented in October 2022, was not adhered to, as evidenced by the lack of proper documentation and communication regarding the water management program and infection surveillance activities. The facility's assessment also lacked information on infection prevention and water management, which was acknowledged by the Director of Nursing as an accidental omission. Interviews with facility staff revealed a lack of awareness and proper implementation of the water management program. The Director of Maintenance admitted to not conducting necessary water testing for Legionella or other pathogens, and the Regional Director was unaware of the current water testing procedures. The Assistant Director of Nursing acknowledged the failure to accurately track and document COVID-19 cases, attributing it to a lack of communication and oversight. These deficiencies highlight significant gaps in the facility's infection prevention and control measures, posing a risk to resident safety.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) completed the required annual 12 hours of educational training. Specifically, CNA-C and CNA-D did not meet the training requirements, with CNA-C completing only 8 hours and CNA-D completing only 7 hours of training in the last 12 months. This deficiency was identified through a record review and staff interview conducted by the surveyor. The Nursing Home Administrator and Director of Nursing were informed of these findings, but no additional information was provided to explain why the facility did not ensure the completion of the required training hours.
Failure to Complete Advance Directive Forms for Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record contained signed advance directive election forms, specifically regarding Cardiopulmonary Resuscitation (CPR). The resident, who had multiple diagnoses including muscle wasting, atrial fibrillation, and dementia, was admitted without a completed advance directive form. The facility's policy requires that upon admission, the facility should determine if a resident has an advance directive and provide information about the right to refuse treatment. However, the resident's CPR consent form was not completed until the surveyor requested it, and there was no care plan for advance directives initiated. Interviews with facility staff revealed that the resident's guardian had not signed the form, and there was no documentation of discussions with the resident or guardian regarding advance directives. The Director of Nursing acknowledged that the code status should be included in the care plan, but it was not. The surveyor noted that the form was only completed after the issue was brought to the facility's attention, and there was still no physician order or care plan for the resident's advance directive in the electronic medical record.
Deficiency in Dialysis Care Coordination
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R426, who required such services. Upon admission, R426 did not have physician orders for hemodialysis or the frequency of dialysis sessions. Additionally, there were no assessments completed before or after dialysis sessions, and no care plan was in place to monitor and care for R426 in relation to dialysis and potential complications. The facility also lacked communication with the dialysis center for each visit, which is a critical component of coordinated care. R426 was admitted with multiple diagnoses, including sepsis, acute pyelonephritis, legionnaires' disease, dependence on renal dialysis, rhabdomyolysis, end-stage renal disease, and type 2 diabetes mellitus. Despite these complex medical needs, the facility's records did not reflect any physician orders or assessments related to dialysis sessions. The care plan for R426 was only updated after the surveyor's inquiry, indicating a lack of proactive management of the resident's dialysis needs. The Director of Nursing (DON) was unable to provide information regarding the resident's dialysis care when initially asked by the surveyor. It was later revealed that there was no communication between the facility and the dialysis center regarding R426's condition and treatment. The facility's policy required comprehensive care plans and coordination with the dialysis provider, which were not adhered to in this case. The lack of documentation and communication highlights a significant deficiency in the facility's management of dialysis care for R426.
Deficiencies in Bed Rail Assessment and Maintenance
Penalty
Summary
The facility failed to ensure proper assessment and informed consent for the use of bed rails for two residents, R7 and R66. R7's Bed Rail Assessment and Informed Consent for Use were not updated since early 2024, despite the presence of grab bars on both sides of the bed. The facility's policy requires these assessments to be reviewed quarterly, but this was not adhered to, as confirmed by the Director of Nursing (DON). R66 had a right grab bar attached to the bed frame, but there was no evidence that risks were explained or informed consent was obtained. The Bed Rail Assessment form for R66 was unsigned, and no informed consent was documented. Additionally, the facility did not enforce a routine maintenance and inspection schedule for bed rails. The Director of Maintenance confirmed that checks on bed canes were only performed when they were removed and reinstalled, with no scheduled inspections when the canes remained on the bed. This lack of regular maintenance and inspection was highlighted during the surveyor's interviews with facility staff. The facility's policy on the proper use of bed rails emphasizes a person-centered approach, requiring comprehensive assessments and informed consent before installation. However, the facility failed to comply with these guidelines, as evidenced by the lack of updated assessments and informed consent for R7 and R66, and the absence of a regular maintenance program for bed rails. These deficiencies were communicated to the facility's leadership during the surveyor's end-of-day meetings.
Governing Body's Financial Mismanagement Leads to Vendor Payment Delays
Penalty
Summary
The facility's governing body failed to establish and implement effective policies and procedures for managing and operating the facility, leading to significant financial mismanagement. This deficiency was identified during a survey where it was found that the facility's fiscal accounts were in arrears, affecting the payment to multiple vendors. The governing body did not ensure that contracted vendors were reimbursed and paid according to established contracts or invoiced amounts, which could potentially impact the care and treatment of all 75 residents in the facility. The survey revealed that the facility owed substantial amounts to various vendors, including those providing essential services such as waste management, pharmacy services, human resources consulting, electronic medical records, food distribution, and medical equipment. For instance, the facility owed over $1.2 million to AlixaRx for pharmacy services, with invoices outstanding for more than 151 days. Additionally, the facility had significant outstanding balances with Sysco Baraboo, a food distributor, and Point Click Care Technologies, which provides electronic medical records, both of which threatened service disruptions due to non-payment. Interviews with facility staff, including the Business Office Manager and the Nursing Home Administrator, indicated a lack of awareness or involvement in the financial issues, with responsibilities for payment and vendor management being deferred to external entities or consultants. The facility's financial instability was further highlighted by the outstanding balances owed to the Wisconsin Department of Health Services for bed tax fees and civil money penalties issued by CMS. The governing body's failure to ensure fiscal stability and oversight has the potential to affect the safety and care of all residents in the facility.
Failure to Prevent Abuse Due to Inadequate Screening
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, specifically in the case of a CNA who was involved in an allegation of sexual assault against a resident. The CNA inaccurately completed a Background Information Disclosure (BID) form by answering 'no' to a question about past criminal convictions, despite having a conviction for fourth-degree sexual assault. The facility did not verify the positive results of the Department of Justice (DOJ) background check against the BID form, nor did it obtain references for the CNA as part of the hiring process. This lack of thorough screening allowed the CNA to care for a resident who later alleged sexual assault. The resident involved in the allegation had a history of right and left above-knee amputation, hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, and depression. The resident was assessed as cognitively intact in April but showed a decline to moderate cognitive impairment by June. The resident alleged that the CNA entered her room, touched her inappropriately, and forced her to touch him. Despite calling for help, no staff responded at the time of the incident. The resident reported the incident to a social worker the following morning, who then notified the Director of Nursing, the police, and the resident's Power of Attorney. The facility's failure to ensure the accuracy of the CNA's BID form and to conduct thorough background and reference checks allowed the CNA to provide care to a vulnerable resident, resulting in the resident alleging sexual abuse. This deficiency created a finding of immediate jeopardy, indicating a reasonable likelihood for serious harm. The facility's inaction in verifying the CNA's background and responding to the resident's calls for help contributed to the severity of the situation.
Failure to Provide Adequate Care and Monitoring for Resident with Diarrhea
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, identified as R6, did not receive a complete blood count (CBC) and basic metabolic panel (BMP) during the specified week as ordered by the physician. This lapse in care was attributed to a break in service from the lab due to unpaid bills by the facility, which was not documented or communicated effectively. Additionally, there was no documentation of the resident refusing the lab work, as claimed by the LPN/UM. R6 experienced multiple episodes of loose, watery diarrhea, which were documented by CNAs but not adequately assessed by the facility. Despite the documentation of 14 episodes of diarrhea, the facility did not obtain a stool sample to rule out an infectious process. The resident was eventually discharged to a family member and subsequently diagnosed with dehydration, C-Diff, and a urinary tract infection at the hospital. The delay in ordering Metamucil and the lack of a comprehensive assessment of the resident's bowel condition contributed to the deficiency. The facility's failure to monitor and report the resident's bowel status and obtain necessary lab work highlights a significant lapse in care. The APNP and nursing staff did not adequately communicate or document the resident's condition, leading to a lack of timely intervention. The facility's policy on incontinence was not followed, as appropriate treatment to prevent infections and restore continence was not provided. This deficiency underscores the need for improved communication, documentation, and adherence to care plans to ensure resident safety and well-being.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R4 and R5, who were at high risk for pressure injuries. R4, who was dependent on staff for bed mobility and had a high Braden Score indicating risk, developed a stage 3 pressure injury on her buttock and a Deep Tissue Injury (DTI) on her left heel. Despite these developments, the care plan was not revised to include necessary interventions such as offloading, turning, and repositioning. Initial assessments and measurements of the pressure injuries were not completed, and treatment was not immediately implemented. R5, who required maximal assistance for bed mobility, also developed a DTI on his right heel. Similar to R4, the facility did not implement care plan interventions for offloading, turning, and repositioning. There was no comprehensive assessment or measurements of R5's pressure injury, and documentation of the injury was lacking in the medical record. The facility's failure to document and assess the pressure injuries in a timely manner contributed to the deficiency. The facility's policy on pressure injury prevention was not followed, as evidenced by the lack of individualized interventions and documentation in the care plans for both residents. The facility's staff, including the wound care nurse, did not perform necessary assessments or implement physician-ordered treatments promptly. The facility's Director of Nursing acknowledged the issues with documentation and treatment, indicating that previous staff had not adhered to proper procedures, which led to the deficiencies identified by the surveyor.
Deficiency in QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that staff received the required annual Quality Assurance and Performance Improvement (QAPI) training, as evidenced by the lack of training documentation for 4 out of 5 Certified Nursing Assistants (CNAs) reviewed. The facility's policy mandates that training requirements be met annually and that the elements and goals of the facility's QAPI program be included in the training content. However, the surveyor found that the facility did not provide the necessary QAPI training to the majority of the CNAs reviewed, which could potentially affect all 69 residents in the facility. During the survey, the Director of Nursing (DON) acknowledged the issue, stating that a change in training software had occurred and that they did not have access to the previous system to verify training completion. Although the Nursing Home Administrator (NHA) later provided documentation confirming that other required trainings were completed, it was confirmed that only one CNA had completed the QAPI training. The facility was unable to provide documentation for the remaining four CNAs, indicating a deficiency in meeting the training requirements as per their policy.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident who was self-administering Entresto, a medication for heart failure, without proper assessment and authorization. The resident, who was admitted with a diagnosis of chronic heart failure, was documented as self-administering the medication from April 18, 2024, to May 3, 2024. However, there was no self-administration assessment completed, no physician's order for self-administration, and no care plan in place regarding the self-administration of medication. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medication, along with a prescriber's order and documentation in the care plan. Despite these requirements, the resident's medication administration record indicated unsupervised self-administration without the necessary assessments or orders. The issue was identified by the facility, and the resident's medications were subsequently administered by the facility starting May 3, 2024. The deficiency was brought to the attention of the facility's administration during a surveyor's exit meeting.
Resident's Mail Privacy Breach
Penalty
Summary
The facility failed to ensure a resident's right to privacy was maintained when receiving mail. A resident, identified as R7, who was cognitively intact, reported that their mail was delivered opened. The incident involved a package that was opened by an LPN without the resident's permission. The Director of Nursing (DON) confirmed that the package was opened by the LPN after being instructed by a receptionist to ensure the contents were safe. The LPN was told by the receptionist that the resident had been ordering knives, which prompted the opening of the package. However, the package contained medication, and the LPN had to explain to the resident why the package was opened. The receptionist, when interviewed, denied instructing staff to open residents' mail. Despite this, the DON maintained that the receptionist had instructed the LPN to open the package. The facility's policy on communication and mail handling, dated 3/26/2023, states that residents' rights to send and receive mail should be protected, and mail should not be opened by staff. The incident was brought to the attention of the Nursing Home Administrator and the DON, but no additional information was provided as to why the facility did not ensure the resident's right to privacy was maintained.
Failure to Promptly Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly investigate and resolve grievances for three residents, identified as R16, R17, and R18, during a survey. The facility's grievance policy mandates prompt resolution and communication with residents throughout the process, overseen by a designated Grievance Official. However, the surveyor found that grievances were not documented or investigated until prompted by the surveyor's inquiries. For R16, a grievance was noted during an abuse investigation, but the facility did not start investigating until after the surveyor's request, and the grievance remained unresolved. Similarly, R17's grievance was not addressed until the surveyor inquired about it. The resident had expressed concerns about a staff member's behavior and issues with call light responses. The facility's investigation summary did not address these specific concerns, and the grievance was not resolved. R18 also reported inappropriate behavior from a staff member during an abuse investigation, but the facility did not begin investigating until after the surveyor's inquiry, and the grievance remained unresolved. The surveyor noted that the facility's grievance process was not followed, as grievances were not promptly investigated or resolved, and documentation was incomplete. The facility's failure to adhere to its grievance policy resulted in unresolved grievances for the three residents, highlighting a deficiency in the facility's handling of resident concerns.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of alleged abuse involving residents R10 and R3 to the State survey agency and/or Nursing Home Administrator within the required timeframe. In the first incident, an allegation of sexual assault involving R10 was not reported to the Administrator and the State agency immediately, but rather several hours after the allegation was made. R10, who has moderate cognitive impairment, reported the incident to Social Services, who then informed the Director of Nursing. However, the report to the State agency was delayed until later in the day, well beyond the required two-hour window. In the second incident, an allegation of physical abuse involving R3 was not reported to the State Survey agency within the required two-hour timeframe. R3 reported being physically mishandled by staff, but the facility did not submit the necessary documentation to the State agency until two days after the incident was discovered. The Director of Nursing was unable to provide an explanation for the delay, as the employee responsible for submitting the report was no longer employed at the facility. The facility's policy mandates that all alleged violations be reported to the appropriate authorities within specified timeframes, particularly when the allegations involve abuse or result in serious bodily injury. Despite this policy, the facility failed to adhere to these requirements in both cases, resulting in a deficiency noted by the surveyors.
Incomplete Investigations into Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse, misappropriation of property, and mistreatment for three residents. Resident R10, who has a moderate cognitive impairment, reported a sexual assault by a staff member. The facility's investigation was incomplete as it only included interviews with two staff members present during the alleged incident, leaving out other staff who were on duty that night. The Director of Nursing could not explain why the investigation was not comprehensive. Resident R15, who is cognitively intact, reported missing money and an incident where a CNA did not assist with toileting and behaved inappropriately. The facility's investigation did not include interviews with all relevant staff, including those who might have been present when the money went missing or who could have witnessed the interaction with the CNA. The Nursing Home Administrator acknowledged the lack of thoroughness in the investigation. Resident R11 alleged neglect, stating that a CNA refused care and threw bedding at her. The facility's investigation included resident statements but failed to ask staff if they had any knowledge of the incident. The Director of Nursing, who was not in her role at the time, indicated that staff should have been questioned about their awareness of the situation. The facility did not provide additional information to explain the incomplete investigation.
Failure to Document and Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, received necessary assistance with activities of daily living, specifically in maintaining good grooming and personal hygiene. R7, who was cognitively intact and required substantial assistance for bathing, did not have any documented showers from mid-April to mid-May 2024. Despite R7's expressed importance of choosing between different types of baths, the facility's records and interviews revealed a lack of documentation and execution of scheduled showers for R7. Interviews with facility staff, including a CNA and LPN, indicated that a new system for tracking showers was implemented in March due to previous issues with missed showers. However, the system failed to ensure R7 received weekly showers as scheduled. The LPN and DON were unable to provide any documentation proving that R7 received showers during the specified period, highlighting a breakdown in the facility's process for ensuring residents' hygiene needs were met.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall prevention interventions for a resident identified as R10. R10 has a medical history that includes hemiplegia and hemiparesis following a cerebral infarction, hypertension, and bilateral above-knee amputation. The resident's care plan, initiated on February 15, 2024, included specific interventions to prevent falls, such as ensuring the call light and personal items were within reach, maintaining a well-lit and clutter-free environment, and placing a body pillow on the side of the bed closest to the door. However, during multiple observations on June 26 and June 27, 2024, the surveyor noted that the body pillow was not present on the right side of R10's bed, which was closest to the door, and the call light was not consistently within reach. Despite the care plan's directives, the surveyor observed R10 in bed without the body pillow on the right side during several checks, and the call light was found on the floor on one occasion. When questioned, R10 indicated that the staff only sometimes placed a pillow alongside her. The LPN/Unit Manager confirmed that the interventions should have been in place according to the care plan. The Nursing Home Administrator and Director of Nursing were informed of these observations, but no explanation was provided for the failure to implement the fall prevention measures as outlined in R10's care plan.
Deficiency in Respiratory Care for Resident Using CPAP
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R7, who required the use of a CPAP machine. The deficiency was noted during an interview and record review, where it was found that R7 did not have medical doctor (MD) orders documenting the settings or cleaning schedule for the CPAP machine, as required by the facility's policy. Additionally, R7's care plan did not address the use of the CPAP machine, despite the resident's diagnoses of Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Sleep Apnea. The hospital discharge summary for R7 indicated the continuation of PAP therapy at bedtime, but this was not reflected in the facility's documentation. The surveyor's investigation revealed that the facility typically receives CPAP orders before a resident's arrival, and the machine is set up with the correct settings at that time. However, in R7's case, there was no documentation in the Medication Administration Record (MAR) regarding the use, cleaning, or maintenance of the CPAP machine. During an interview, the LPN Unit Manager confirmed that residents using CPAP machines should have corresponding orders and care plans, which were absent for R7. The issue was brought to the attention of the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing during the exit meeting, but no additional information was provided to explain the oversight.
Significant Medication Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that two residents, R8 and R9, were free from significant medication errors. R8, who had a kidney transplant, was prescribed Tacrolimus to prevent organ rejection. However, during the first five days of R8's admission, the resident missed six out of eleven doses due to the medication being unavailable. The facility's policy required staff to notify the pharmacy and the attending physician if medications were unavailable, but there was no specific policy on when to notify a provider after a resident missed medication. Interviews with staff revealed that the medication was not in the contingency supply, and there was a lack of documentation explaining the missed doses. R9, diagnosed with atrial fibrillation and heart failure, was prescribed Ivabradine. Between January 4 and January 9, 2024, R9 missed nine out of ten doses of the medication. Similar to R8's case, the medication was not available, and there was no documentation regarding the missed doses. Interviews with staff indicated that the facility had recently changed pharmacy providers due to previous issues with medication availability, but the new system had not yet resolved the problem for R9. The facility's Director of Nursing and Assistant Director of Nursing were unable to provide explanations for the missed doses for both residents. The surveyor noted that the facility's process for handling unavailable medications was inadequate, as there was no clear policy on notifying providers after missed doses, and the contingency supply did not include the necessary medications. The facility's failure to ensure the availability and administration of critical medications resulted in significant medication errors for both residents.
Inaccurate Medical Record Documentation for Resident with Amputations
Penalty
Summary
The facility failed to maintain accurate medical records for a resident identified as R10, who has a medical history of diabetes mellitus and bilateral above-knee amputations. Despite the resident's condition, the facility's records inaccurately documented that diabetic foot checks were being performed daily, as per a physician's order dated 4/4/24. This order required daily diabetic foot checks at bedtime, which were recorded as completed on the resident's medication administration records (MAR) for April, May, and June 2024. However, the resident does not have feet, making these documented checks impossible. The deficiency was identified during a surveyor's review of the resident's MAR and through interviews with facility staff. On 6/26/24, the surveyor observed the resident and confirmed the bilateral above-knee amputations. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that checks and initials on the MAR indicated that the treatment was performed. The DON acknowledged that the issue was supposed to have been corrected, yet the MAR continued to reflect the completion of diabetic foot checks as of June 25th, 2024.
Failure to Ensure Appropriate Treatment and Care
Penalty
Summary
The facility did not ensure that a resident received appropriate treatment and care according to orders, preferences, and goals. The resident, who had a history of significant medical conditions including COPD, diabetes, atrial fibrillation, and coronary artery disease, complained of pain across his chest and rib area. A Med Tech administered Tylenol but failed to alert a Registered Nurse to assess the resident's cardiac status, obtain vital signs, or determine the resident's pain level on a 0 to 10 scale. The Med Tech also did not follow up to verify the effectiveness of the medication and did not notify the attending physician of the resident's chest pain and potential change in condition. The facility's policy on Notification of Changes requires immediate communication of significant changes in a resident's condition to the resident, their representative, and the attending physician. Despite this policy, the Med Tech did not report the resident's chest pain to a nurse or ensure a follow-up assessment was conducted. The Med Tech documented the medication as effective without verifying this with the resident, and no Registered Nurse assessment or physician notification was made regarding the resident's chest pain. Interviews with facility staff, including the Med Tech, an Agency LPN, the attending physician, and the Director of Nursing, confirmed the lack of appropriate follow-up and communication. The Med Tech admitted to not considering the pain as chest pain and did not report it to a nurse. The attending physician stated that he would have wanted to be notified and would have expected a set of vital signs. The Director of Nursing acknowledged that the Med Tech should have reviewed the information with a nurse and that someone should have followed up with the resident and updated the physician if the pain was not effectively managed.
Failure to Monitor Warfarin Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs and adequately monitored for Warfarin side effects. The resident was admitted with an order for Warfarin, but the facility did not implement a care plan or orders to monitor for adverse side effects associated with anticoagulant therapy. The facility's policy on managing anticoagulant therapy was not followed, as there were no documented target symptoms, goals for use, or routine lab orders communicated to the physician in a timely manner. Additionally, the care plan did not include interventions to minimize the risk of adverse consequences, such as monitoring for bleeding and bruising, which are critical for residents on anticoagulant therapy. The surveyor's review of the resident's medical records revealed that the order to monitor for signs and symptoms of bleeding was vague and did not specify the source or location of the bleeding. Interviews with the MD and DON confirmed that staff should be monitoring for signs of side effects, including bleeding, bruising, changes in condition, and cardiac symptoms. Both the MD and DON acknowledged that there should have been specific orders and a care plan in place to guide staff in monitoring for these side effects. The lack of a comprehensive care plan and specific monitoring orders led to the deficiency identified by the surveyor.
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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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