Jewish Home And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 1414 N Prospect Ave, Milwaukee, Wisconsin 53202
- CMS Provider Number
- 525172
- Inspections on file
- 20
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 10 (3 serious)
Citation history
Health deficiencies cited at Jewish Home And Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to honor DNR advance directives for two residents, both of whom had completed CPR preference forms and state DNR documentation indicating they did not want resuscitation. In one case, a resident with an activated POA and signed CPR preference form experienced a cardiopulmonary arrest; staff initiated CPR, and EMS continued full resuscitation because there was no DNR bracelet and the state DNR form lacked a physician signature at the time, despite staff believing the resident was DNR. In the second case, a cognitively intact resident with cancer and a physician-signed emergency DNR form became unresponsive after a meal; staff started CPR and EMS continued it even after being shown DNR paperwork, only stopping when a DNR bracelet was eventually found under the resident’s clothing. Supervisory nursing staff reported they did not know the residents’ code status before starting CPR, and the facility’s internal incident review did not address the CPR provided contrary to one resident’s documented no-CPR status.
Two residents did not receive care consistent with standards of practice when their conditions changed. One resident with a clearly documented fish allergy was served fish at a meal, consumed some, and developed a low heart rate and loss of consciousness; staff notified an LPN and supervisor, took vitals, texted the MD, and called 911, but did not recognize an allergic reaction or administer epinephrine, and there was no anaphylaxis policy or epi-pen available, resulting in an Immediate Jeopardy finding. Another resident with diabetes, ESRD, and prior foot amputations was readmitted with a necrotic wound on the distal right foot, but documentation was incomplete and a treatment order was incorrectly entered for a DTI on the right heel; the correct plantar foot diabetic ulcer was not comprehensively assessed or accurately documented until several days later, and a hospital order for right foot ulcer care was not transcribed, leading to ongoing treatment of the wrong site.
A resident with lung and breast cancer, cognitively intact, had a fish allergy documented by the RD but without details on type, reaction, or severity, and this allergy was not reflected in the MDS, CAA, or care plan, although it appeared in the physician’s plan of care and on the dietary meal ticket. The RD did not further assess the allergy, and the dietary process relied on electronic communication of allergies to the menu system. On one occasion, the resident was served a combo meal that included fish despite the allergy notation on the meal ticket; later, a CNA discovered the fish on the plate, confirmed the allergy on the ticket, and notified nursing. The resident subsequently exhibited clinical changes including bradycardia, anxiety, trembling, loss of consciousness, shaking, and absence of a palpable pulse, and the facility’s investigation determined the resident had received fish and experienced an allergic reaction that led to death, resulting in an Immediate Jeopardy finding.
The facility failed to maintain an effective infection prevention and control program when infection surveillance logs for multiple months were incomplete or missing key information, including organisms, criteria definitions, and tracking of infections. A COVID outbreak and a gastrointestinal illness involving residents and staff were only partially documented with line lists and an email, without investigation summaries to determine etiology or preventive measures. The designated IP had recently assumed the role and was absent and then terminated, and the ADON, who previously served as IP, reported that there were no documents for tracking and trending infections or outbreaks for the prior three months, although antibiotic use was tracked separately.
The facility failed to follow its own policies for offering, obtaining consent for, and documenting pneumococcal and influenza vaccinations. Several residents had prior PPSV23 documented and were eligible for PCV vaccines, yet there was no admission documentation that PCV20, PCV21, or PCV15 were offered. In multiple cases, residents signed consent forms indicating PPSV23, but the forms documented administration of PCV20, with no evidence that PCV20 had been offered or specifically consented to. One resident had no documentation of any pneumococcal or influenza vaccines or that influenza vaccination was offered. The ADON reported that admissions are reviewed in the state immunization registry and residents are screened and offered required vaccines, but also stated that PCV vaccines had not been administered for several years and that this was the first year PCV had been ordered.
A resident’s right to a safe, clean, and homelike environment was not honored when a large wall panel in the resident’s room was found leaning against the wall instead of covering an opening that exposed a filter and electrical components. The surveyor observed the exposed opening on multiple days, and the Director of Plant Operations reported not having received any notification or work order about this specific room, despite having recently repaired a similar panel in another room. The issue remained unaddressed for several days until it was brought to facility leadership’s attention.
The facility failed to follow its abuse reporting policy in two separate cases. In one case, a cognitively intact resident who required assistance with ADLs reported that a CNA pushed them onto a toilet, causing their head to hit the wall; although nursing staff promptly informed the supervisor and leadership, the allegation was not reported to the State Agency within the required 2-hour timeframe. In the second case, a resident with a right femur fracture and an injury of unknown source, classified as suspicious due to its extent or location, was reported to the State Agency, but law enforcement was not notified despite facility policy requiring immediate reporting of suspected crimes. The DSS indicated that the NHA decides when to contact police, and the NHA stated they typically notify law enforcement only for certain types of physical abuse or substantial misappropriation and believed the fracture might be related to a prior fall.
Two residents were affected when the facility failed to maintain a safe environment and adequate supervision. One resident with anxiety, depression, asthma, and rheumatoid arthritis began smoking while in care; although a smoking safety screen documented conflicting information about whether she was safe to smoke independently and noted that she needed supervision and facility storage of smoking materials, her care plan was never updated to reflect that she smoked, her supervision needs, or control of cigarettes and lighters, even as staff documented multiple episodes of her smoking outside and possessing smoking materials. Another resident with dementia, CHF, chronic respiratory failure, diabetes, and high fall risk had a care plan requiring two-person assistance for transfers between wheelchair and shower chair, but during a shower a CNA transferred the resident with only one staff member, the resident’s leg gave out, and the CNA lowered the resident to the shower room floor, as confirmed by fall investigation documentation.
A resident with RA, fibromyalgia, and chronic pain experienced worsening pain after a previously effective RA medication was discontinued due to insurance, yet the facility did not complete timely follow‑up pain evaluations, did not update the care plan when pain progressed from mild to severe and began interfering with sleep, therapy, and daily activities, and did not document use of ordered non‑pharmacological interventions. Despite frequent use of scheduled acetaminophen and gabapentin plus PRN acetaminophen and hydromorphone for pain scores up to 10, the care plan was not revised to reflect severe daily pain or to incorporate additional strategies beyond oral medications, and the acceptable pain level was only defined late in the review period. The resident reported increased pain and reduced activity participation, while the physician acknowledged increased breakthrough pain after the RA drug change, and surveyors found no evidence that the facility comprehensively assessed the pain escalation, updated the person‑centered plan of care, or sought alternative arthritis treatments.
The facility did not follow its COVID-19 vaccination policy requiring that residents be educated on and offered the COVID-19 vaccine at admission, with documentation of education, administration, refusal, or contraindication in the medical record. Record review showed that three newly admitted residents had no documentation that the COVID-19 vaccine was offered, that risks and benefits were reviewed, or that the vaccine was given, refused, or contraindicated. The ADON reported that the standard process includes checking the Wisconsin Immunization Registry, screening vaccine history, offering vaccines, obtaining consent, and reviewing risks and benefits, but this process was not reflected in the records reviewed, as confirmed and discussed with facility leadership during the survey exit meeting.
Narcotic count sheets for all medication carts were not consistently signed by two nurses at each shift change, as required by facility policy. Multiple instances were found where either the counting or recording nurse, or both, failed to sign off, and nursing staff as well as the DON confirmed these omissions during interviews.
The facility failed to adhere to food safety standards, with undated and improperly stored food items observed in the kitchen and fourth-floor fridge. Additionally, staff did not use hair restraints, despite their availability, while working in the kitchen. These deficiencies were noted by surveyors and discussed with facility management.
The facility failed to conduct annual N95 respirator fit testing for 34 staff members, as required by their Covid-19 Respiratory Protection Program policy. The deficiency was identified through interviews and record reviews, revealing overdue fit test dates for staff in various departments, including direct care and environmental services. The DON acknowledged the issue, but updated records still showed overdue dates, and the NHA had no additional information.
The facility failed to ensure comprehensive assessments and limit PRN orders for psychotropic medications to 14 days for three residents. One resident continued to receive Trazodone without a current signed consent and missed quarterly sleep assessments. Another resident's PRN Trazodone order lacked a stop date and was used beyond 14 days without proper documentation. A third resident's PRN Ativan order also lacked a stop date, and the physician declined a pharmacist's recommendation to evaluate its use without providing a rationale.
The facility failed to ensure proper communication and documentation of hospice services for two residents receiving hospice care. For one resident with chronic conditions, the facility lacked access to necessary hospice documentation, including the hospice election statement and recertification orders. Similarly, for another resident with dementia, the facility lacked adequate communication and documentation from the hospice provider. The lack of communication and documentation led to deficiencies in coordinating care for both residents.
A resident with complex medical conditions, including end-stage renal disease, did not receive the prescribed two tablets of Hydrocodone-Acetaminophen before dialysis due to a misinterpretation of medication orders by nursing staff. The resident, who experiences frequent and intense pain, was given only one tablet, contrary to the physician's orders for additional pain management on dialysis days. The error was acknowledged by the RN Manager and DON as a misreading of the orders.
A resident in a long-term care facility experienced significant medication errors when they were administered a double dose of Clonazepam and, on a separate occasion, Morphine instead of Clonazepam. These errors were attributed to staff distractions and improper medication handling. The resident, with a complex medical history, required close monitoring due to potential adverse reactions. The facility's policies on medication administration and error reporting were not adequately followed, leading to deficiencies in staff training and protocol adherence.
Failure to Honor DNR Advance Directives Resulting in CPR on Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ advance directives, specifically Do Not Resuscitate (DNR) orders, were implemented as requested, resulting in CPR being performed on two residents who had chosen not to receive it. Facility policy dated 1/17 states that basic life support, including CPR, will be provided when needed, subject to physician order and resident choice as indicated in advance directives, and that CPR is not to be initiated when a valid DNR order is in place. Surveyors determined that the facility did not follow through on obtaining and processing valid physician-signed DNR orders and did not consistently verify and honor residents’ code status before initiating CPR. One resident, R102, was admitted with dementia, anxiety, and cellulitis and had been deemed incapacitated at the hospital. A Power of Attorney for Health Care (POAHC) was activated, and upon admission the POAHC signed a CPR preference form indicating that R102 did not want CPR in the event of cardiopulmonary arrest. The form stated that the physician must provide an order to withhold CPR for inclusion in the medical record, based in part on the resident’s preferences. The POAHC later signed the State of Wisconsin Emergency Care DNR form, which is used to request a DNR bracelet and outlines that only the bracelet identifies DNR status to EMS responders. On the day of the event, nursing notes document that R102 became unresponsive after heavy breathing and a seizure; staff attempted to obtain vitals, applied oxygen, called 911, and started CPR. The ADON later reported that she checked the chart, saw a red cover indicating DNR status, and informed the floor nurse that the resident was DNR, but CPR continued and EMS arrived to find staff performing CPR. The paramedic report for R102 documents that staff stated they believed the resident was DNR but that there was no DNR identification such as a bracelet. Staff produced the State of Wisconsin DNR form, but it lacked a physician signature at that time, and other documents such as the POAHC and living will were also provided. Because the DNR form was not signed by a physician and there was no DNR bracelet, paramedics continued CPR, including mechanical CPR, intraosseous access, airway placement, and administration of epinephrine, until they received confirmation allowing them to stop. The State of Wisconsin DNR form for R102 was not signed by a physician until after the resident had received CPR and died. The DON later stated that if there is no legally signed DNR form by the physician, nurses are required to perform CPR, and surveyors identified that the facility had not followed through in obtaining the physician’s signature despite the resident’s documented wishes for no life-sustaining measures. A second resident, R24, had diagnoses of lung and breast cancer and was cognitively intact per a BIMS assessment. R24 completed a CPR preference form indicating that CPR was not wanted in the event of cardiac arrest, and an Advance Directive for Emergency Care DNR form was signed by the resident’s physician. On the day of the incident, R24, who had a documented fish allergy, was served fish for lunch. During subsequent vital sign assessment, R24 became unresponsive, briefly recovered, then became unresponsive again. LPN-Y obtained an AED and started CPR, and 911 was called. The paramedic report states that EMS arrived to find staff performing CPR with mechanical ventilation and an AED in place. During resuscitation, staff presented a form showing the resident was DNR, and CPR was briefly stopped but then resumed because the document was viewed as only a request for a DNR bracelet and staff stated the resident was not wearing a DNR bracelet. The paramedic report for R24 further documents that, after CPR and life-saving measures were resumed, EMS instructed crew to double-check for a DNR bracelet and one was found around the resident’s forearm under a jacket. At that point, CPR was ceased and the resident was pronounced. LPN-S, the supervisor on duty, reported that she did not know the resident’s code status prior to starting CPR and did not observe a DNR bracelet, and that she would normally look in the electronic or paper record for code status. The DON later stated she did not know why staff started CPR on R24. Surveyors noted that the facility’s own Facility Reported Incident investigation focused on the fish allergy issue and did not investigate the concern that R24 received CPR contrary to the documented no-CPR advance directive. The surveyors concluded that the facility failed to ensure that both residents’ advance directive wishes regarding no CPR were honored, resulting in a finding of Immediate Jeopardy affecting all residents.
Failure to Respond to Anaphylaxis and Delay in Comprehensive Wound Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with standards of practice when residents experienced changes in medical condition. One resident with documented lung and breast cancer had a known fish allergy recorded on admission and in a nutrition assessment. Despite this, the resident was served fish at a noon meal and consumed some of it. A CNA recognized the meal as fish, confirmed the allergy on the meal ticket, and notified the assigned LPN and the nursing supervisor. At that time, the resident was coughing and had requested cough medicine and an anxiety pill, and did not initially exhibit hives, tongue swelling, or itchy mouth or throat. Following consumption of the fish, the resident’s vital signs showed a low pulse, elevated blood pressure, respirations of 22, and oxygen saturation of 94% on 4 liters of oxygen, with pale and clammy skin. The resident became unresponsive, then briefly responsive, and agreed to be sent to the hospital. Staff initiated paperwork for transfer, and the supervisor began a text (“tiger text”) to the MD about the low pulse and the fact that the resident had received fish despite a fish allergy. The facility staff did not immediately recognize the situation as an allergic reaction or anaphylaxis and did not administer epinephrine. The MD, who received a text message while with another patient, responded to call 911 and administer an epi-pen, but by that time the resident had already passed away. The facility did not have an anaphylaxis policy and procedure, and the DON stated there were no epi-pens in the medication carts. The facility’s failure to identify the allergic reaction and to administer anaphylaxis interventions immediately resulted in an Immediate Jeopardy finding beginning on 3/15/26, which was not removed by the time of survey exit. A second deficiency involved another resident with end stage renal disease requiring dialysis, diabetes, coronary heart disease, and anxiety, who was readmitted with a wound to the distal end of the right foot where toes had been amputated. On readmission, necrosis was noted to the right foot and an eInteract form documented a necrotic wound, but the description was incomplete and contained conflicting measurements. A treatment order was entered for a deep tissue injury to the right heel, even though the wound was actually located on the distal stump/plantar area where the toes had been amputated. Progress notes and orders repeatedly referenced a right heel wound, and the treatment to the right heel continued, while the actual diabetic ulcer on the right plantar foot was not comprehensively assessed. Over the next several days, the resident was sent to the hospital for evaluation of the right foot, returned with an order to cover the right foot ulcer with gauze and change daily, but this order was not transcribed into the medical record, and the heel treatment order remained in place. The wound physician later documented a diabetic wound to the right plantar foot with specific measurements and necrotic tissue, and this was the first comprehensive assessment of the wound, occurring six days after the initial discovery. Interviews with the MD, RN manager, and RN supervisor revealed confusion and conflicting documentation about the wound’s location, with some staff describing two black areas on the stump and others acknowledging that the order had been entered for the wrong body area. The care plan for the diabetic ulcer of the right plantar foot was not initiated until after the wound physician’s assessment, underscoring that the wound was not comprehensively assessed and documented in a timely or accurate manner.
Failure to Manage Documented Fish Allergy Resulting in Fatal Reaction
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s documented food allergy was thoroughly assessed and consistently integrated into care planning and dietary practices, resulting in the resident receiving fish despite a known fish allergy. The resident was admitted with lung and breast cancer and had a BIMS score of 15, indicating no cognitive impairment. The admission Nursing Data Base Assessment did not document any food allergies. On 1/28/26, the RD completed a Nutrition Assessment that documented a fish allergy but did not specify the type of fish, the resident’s reaction, or the severity. The admission MDS and Nutritional Status CAA completed on 1/30/26 did not document any food allergy, and the resident’s care plan also lacked any entry regarding a fish allergy, including type of fish or severity, although the Physician Plan of Care did document fish as an allergy. The RD reported that the resident verbally disclosed a fish allergy, that she assumed this applied to all types of fish, and that she did not ask for specific details about the reaction or its severity. The RD also stated she does not do care planning and believed all food allergies would be written into the care plan, and that she reviews hospital paperwork for allergies; in this case, no food allergies were documented in the hospital records. The Director of Food Services stated that the menu for the day in question listed a combo cheese and spinach quesadilla, creamed corn, and Mediterranean baked fish, and that a combo plate would include a little of everything, including fish. The DFS stated that the diet technician or RD meets with new admissions for likes, dislikes, and allergies, which are entered into the electronic medical record and communicated to the menu system, and that the resident’s meal ticket did identify the fish allergy, but the cook did not follow it. On the day of the incident, the resident was served fish for lunch and later requested that a CNA heat up leftover food. The CNA observed the food and told the resident it was fish, while the resident believed it was chicken. The resident stated it had better not be fish because they were allergic, prompting the CNA to check the meal ticket, see the fish allergy, and notify the floor nurse and the nursing supervisor. A progress note later documented that around 1500, the supervisor arrived to find the floor nurse taking vitals; the resident was in an armchair, alert, verbal, with vital signs including BP 163/66, pulse 40, respirations 22, temperature 97.2, and oxygen saturation 94% on 4L O2 via nasal cannula, with no shortness of breath, cough, difficulty breathing, or cyanosis, and denying pain. The note describes a subsequent drop in pulse, notification of the MD, instruction to call 911, the resident becoming anxious, trembling, losing consciousness, then briefly responsive, removing and replacing O2, followed by dilated pupils, shaking, arm flailing, loss of consciousness, and absence of a palpable pulse before EMT arrival. The facility’s investigation concluded that the resident received fish and had an allergic reaction, and the resident passed away related to this event, leading to a finding of Immediate Jeopardy beginning on 3/15/26.
Failure to Maintain Effective Infection Surveillance and Outbreak Investigation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, including infection surveillance, tracking, and outbreak investigation, for all 82 residents. Surveyors requested infection control documents from the Assistant DON, who was serving as the Infection Preventionist (IP) in the absence of the designated IP. The IP had started in the role in January 2026 but was out of the facility at the time of the survey and subsequently terminated employment. The Assistant DON provided surveillance and tracking logs for the last three months, but the January surveillance log was not filled out for infection surveillance. Although there was a line list and an email documenting a COVID outbreak with start and end dates, there was no investigation summary to determine the etiology of the outbreak or the preventative measures implemented. For February, the surveillance log did not document organisms identified or tracking of infections, and while there was a line list for a gastrointestinal illness involving residents and staff, there was no additional documentation to interpret this data. The March surveillance log did not thoroughly document organisms, criteria definitions, or tracking of infections. The Assistant DON reported that no additional outbreak investigation information could be located and that the facility did not have documents for tracking and trends of infections or outbreaks for the last three months, although antibiotic use had been tracked separately. The Nursing Home Administrator confirmed that the designated IP had not returned to work since earlier in the week, and there was no evidence of a complete, documented infection surveillance and outbreak investigation process during the period reviewed.
Failure to Properly Offer, Obtain Consent for, and Document Pneumococcal and Influenza Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were appropriately offered and documented for pneumococcal and influenza vaccinations upon admission, as required by facility policy. The facility’s influenza policy states that all residents are to be offered and encouraged to obtain annual influenza immunization, with consent, education on risks and benefits, and documentation of receipt or refusal on the medication administration record. The pneumococcal vaccine policy states that all residents are encouraged to obtain PPSV23 and PCV vaccines (PCV15 or PCV20). Despite these policies, record review and interviews showed that residents were not consistently offered pneumococcal vaccines upon admission, and there was missing or inaccurate documentation of both pneumococcal and influenza vaccines. One resident admitted in 2017 had documentation of PPSV23 in 2017 and was eligible later for PCV20 or PCV21 and then PCV15, but the medical record at admission did not show that these vaccines were offered. This resident signed a consent form for PPSV23 in March 2026, but the form documented administration of PCV20, and there was no evidence the resident had been offered or consented to PCV20 upon admission. Another resident admitted in 2019 had PPSV23 documented in 2019 and was similarly eligible for PCV20 or PCV21 and then PCV15, yet there was no documentation that these vaccines were offered upon admission. This resident also signed a consent form for PPSV23 in March 2026, but the form documented administration of PCV20, again without documentation that PCV20 or PCV21 had been offered at admission or that the resident consented specifically to PCV20. A third resident’s record contained no documentation of any pneumococcal vaccines and no documentation that the influenza vaccine was offered, despite the stated process of reviewing the Wisconsin Immunization Registry, screening for vaccine history, and obtaining consent with education on risks and benefits. Another resident’s medical record did not document any pneumococcal vaccines; later, a pneumonia vaccine consent form was signed for PPSV23, but the form documented administration of PCV20, and there was no evidence that PCV20 or PCV21 had been offered upon admission or that the resident consented to PCV20. A fifth resident had PPSV23 documented in 2019 and would have been eligible for PCV20 or PCV21 and then PCV15, but there was no documentation these were offered upon admission; this resident also signed a consent for PPSV23, while the form documented PCV20 administration without documented consent for PCV20. Throughout interviews, the ADON stated that admissions are reviewed in the Wisconsin Immunization Registry and residents are screened and offered required vaccines, but also acknowledged that PCV vaccines had not been administered for the last couple of years and that this was the first year PCV had been ordered.
Exposed Wall Panel With Electrical Components in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for a resident whose room contained an exposed wall opening with visible electrical components. During an observation on 3/23/2026 at 11:10 AM, the surveyor noted that a large wall panel, approximately three feet by one-and-a-half feet, that should have covered the interior workings of the wall was instead leaning against the wall, leaving an opening through which a filter and other electrical components were visible. A subsequent observation on 3/25/2026 at 7:37 AM showed that the panel remained off the wall and continued to lean against it, with the opening still exposed. In an interview on 3/25/2026 at 8:23 AM, the Director of Plant Operations (DPO) explained that maintenance is notified of needed repairs by radio from the front desk. The DPO reported having recently fixed a loose panel in another room on or around 3/23/2026 but confirmed that this repair did not involve the resident’s room in question. When asked, the DPO stated they were not aware that the panel in this resident’s room was off and later confirmed there had been no notification or work order submitted for this issue. The DPO indicated that a maintenance staff member was then assigned to fix the panel, and the surveyor later informed the Nursing Home Administrator that the panel covering electrical equipment in the resident’s room had been off for the past three days.
Failure to Timely Report Abuse Allegation and Notify Law Enforcement of Suspicious Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the State Agency and to notify law enforcement of a suspicious injury of unknown source, as required by regulation and by the facility’s own abuse policy. The facility’s policy, last reviewed 6/12/25, requires that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately, but not later than 2 hours after the allegation is made, and that all suspected crimes and alleged sexual abuse be immediately reported to local law enforcement. In the case of one resident, an allegation that a CNA pushed the resident onto the toilet causing the resident’s head to hit the wall was not reported to the State Agency within the required 2-hour timeframe. The first resident, who was cognitively intact with a BIMS score of 13 and required partial to moderate assistance with toileting, showering, sit-to-stand, and transfers, reported on the evening of 1/24/26 that a CNA had been rough during care, pushing the resident down on the toilet and causing the resident’s head to strike the wall. A LPN stated that the CNA notified her that the resident was requesting pain medication, and when the LPN entered the room a few minutes later, the resident reported the alleged abuse. The LPN reported the allegation to the nurse supervisor, who in turn reported it to the Nursing Home Administrator and DON, and an investigation was started that same evening. However, the self-report of the allegation was not submitted to the State Agency until the morning of 1/25/26 at 10:56 AM, which exceeded the 2-hour reporting requirement. The Director of Social Services, who is responsible for submitting self-reports and acknowledged that abuse allegations must be submitted within 2 hours, could not recall when or by whom the allegation was reported to her. The second deficiency concerns another resident who was found to have a right femur fracture after being sent to the hospital for right leg pain and was unable to state how the injury occurred. The facility identified this as an injury of unknown source that was suspicious due to the extent or location of the injury and submitted an alleged mistreatment, neglect, and abuse report to the State Agency on the same day it became aware of the fracture. The facility began an investigation by interviewing staff and peers about any knowledge of how the fracture occurred. Despite the facility’s policy requiring that all reports of suspected crime and alleged sexual abuse be immediately reported to local law enforcement, the facility did not notify law enforcement of this suspicious injury of unknown source. The Director of Social Services stated that the Administrator decides whether to notify law enforcement, and the Administrator explained that law enforcement is usually contacted for physical abuse or substantial misappropriation of property and that they believed the fracture might be related to a prior fall, but no additional justification was provided for not notifying law enforcement in this case.
Failure to Ensure Smoking Safety and Adherence to Transfer Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, one related to smoking safety and one related to transfer assistance. For the first resident, who had diagnoses including anxiety disorder, major depressive disorder, mild intermittent asthma, and rheumatoid arthritis, staff became aware in December that she had started smoking while residing at the facility, despite her admission MDS indicating she did not smoke. A nursing note documented that she had been going outside to smoke and that her lighter was confiscated. A Smoking Safety Screen dated in December was the only such assessment in her record and contained contradictory information: it categorized her as safe to smoke without supervision and documented that she smoked 2–5 cigarettes per day, yet in the safety section it stated she needed supervision and required the facility to store her lighter and cigarettes, and IDT notes indicated PT/OT had determined she was not a safe smoker because she could not safely wheel herself off the property and required supervision and assistance to go out to smoke. Despite the Smoking Safety Screen indicating that the plan of care would be used to assure safety while smoking, the resident’s care plan did not reflect that she was a smoker, did not address whether she was to be supervised or could smoke independently, and did not specify whether she could keep smoking materials or needed to turn them in to staff. Social services documentation later noted that the team had spent extensive time discussing smoking policy and safe smoking practices with her, and a nursing note documented that she expressed a desire to quit smoking and agreed to nicotine replacement therapy. However, subsequent nursing documentation showed that she continued to smoke outside, including a note that she had returned from having a smoke and another note describing staff finding her smoking outside in front of the building with cigarettes and a lighter reportedly brought in by her brother. Staff re-educated her on the nonsmoking policy and confiscated paraphernalia, and the DON directed a room sweep, but there was still no updated care plan addressing her smoking status, supervision needs, or control of smoking materials, even though staff were aware she was smoking and had access to her own smoking materials without staff knowledge. The second resident’s deficiency involved failure to follow the established care plan for transfers during bathing, resulting in a witnessed fall. This resident had diagnoses including senile degeneration of the brain, congestive heart failure, chronic respiratory failure with hypoxia, diabetes, vascular dementia, and depression, with a significant change MDS showing moderate cognitive impairment (BIMS 10) and dependence for ADLs. The ADL CAA documented total assistance needs related to impaired mobility and cognition, and the Falls CAA documented fall risk related to incontinence, history of falls, psychotropic medication use, impaired mobility, and impaired cognition. The ADL Care Plan, with a revised intervention for bathing/showering, and the High Risk for Falls Care Plan both documented that the resident required maximum assistance by one staff for bathing/showering and two staff to transfer from the wheelchair to the shower chair. On a documented date, progress notes recorded that during a shower, while the resident was being transferred from the shower chair to the wheelchair, the resident became unsteady and a CNA lowered the resident to the floor. The resident was then lifted from the floor with a full body mechanical lift and three staff members assisting, and no injuries were noted at the time. The Fall Scene Investigation Report and the CNA’s written statement confirmed that the fall occurred during a transfer to the wheelchair with only one CNA assisting; the CNA reported that the resident stood up fine, but when the CNA was scooting the wheelchair underneath, the resident said their leg had given out and began to slide, so the CNA lowered the resident to the shower room floor. The interdisciplinary review note referenced the resident slipping and being lowered to the floor in the shower but did not specify the transfer from shower chair to wheelchair. All available documentation indicated that the transfer was performed with one CNA instead of the two staff required by the resident’s care plan for shower transfers, and facility leadership later acknowledged that the documentation showed the transfer was done with one CNA rather than two.
Failure to Update and Implement Comprehensive Pain Management for a Resident with Worsening Chronic Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and person‑centered pain management for a resident with chronic pain conditions, in accordance with the resident’s goals, preferences, and comprehensive care plan. The resident was admitted with fibromyalgia, anxiety disorder, major depressive disorder, and rheumatoid arthritis affecting multiple sites, and was receiving PT/OT. The care plan identified actual pain related to RA and fibromyalgia and included interventions such as administering analgesia per orders, evaluating effectiveness of pain interventions, and observing and reporting changes in function and behavior. An initial pain evaluation dated 4/7/25 showed a mild pain risk score, and the EMR flagged that an additional pain evaluation due 7/7/25 was more than 260 days overdue, indicating that updated pain assessments were not completed as scheduled. Over time, the resident’s pain increased, particularly after a RA medication that had been effective was discontinued because insurance would no longer pay for it. Nursing notes documented ongoing complaints of left hip pain, back pain with crying when sitting up, and episodes of knee and leg pain where the resident reported that pills were not helping. The resident was frequently using scheduled and PRN pain medications, including acetaminophen, gabapentin, and hydromorphone, with documented pain scores ranging from 3 to 10. The quarterly MDS dated 11/20/25 documented no pain in the last 5 days and no interference with sleep or therapy, but a subsequent quarterly pain interview on 11/26/25 documented frequent pain, difficulty sleeping due to pain, and a pain intensity of 7 (severe), with daily vocal complaints of pain. Despite this, there were no updates to the care plan to reflect severe daily pain or to add new interventions, and the pain interview lacked documentation of interventions or their effectiveness. By the time of the annual MDS on 2/28/26, the resident was documented as frequently having severe pain that interfered with sleep, therapy, and day‑to‑day activities, and the pain CAA directed staff to proceed to care plan with an objective of improvement and symptom relief. However, surveyor review showed the care plan had not been updated to address the change from no pain on the earlier MDS to severe, function‑impacting pain, and there were no new interventions or assessment of what pain level was tolerable or acceptable to the resident until a late nursing order on 3/19/26 set an acceptable pain level at 4/10. From 3/1/26 to 3/25/26, the resident received frequent PRN hydromorphone (43 doses) and PRN acetaminophen in addition to scheduled medications, with multiple instances where the pain goal was not met, yet there was no documentation that non‑pharmacological interventions were implemented despite an active order listing repositioning, distraction, warm blankets, back rubs, ice, and other measures. The resident reported that pain had worsened, that she sometimes used a cream and lying down for relief, and that she attended fewer activities because of pain. At exit, the facility had not provided information explaining why the resident’s increased pain and frequency were not comprehensively assessed, why the care plan was not updated with additional interventions beyond oral medications, or why alternatives to the discontinued RA medication with previously good effect were not pursued.
Failure to Document Offering and Education of COVID-19 Vaccination on Admission
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine with education on risks and benefits and that this was documented in the medical record, as required by its own COVID-19 vaccination policy revised 8/24. The policy states that the facility will educate and offer the COVID-19 vaccine to residents and staff, maintain documentation of such, and that the resident medical record must include documentation of education on risks, benefits, and potential side effects, each dose administered, or documentation of medical contraindication or refusal. Record review showed that three residents (R35, R7, and R6) admitted to the facility on various dates had no documentation in their medical records that the COVID-19 vaccine was offered upon admission, that they received the vaccine, or that they were educated on the risks and benefits. During interviews on 3/26/2026 at 11:31 AM, the ADON stated that the facility’s immunization process includes reviewing new admissions in the Wisconsin Immunization Registry (WIR), screening residents for vaccine history, offering required vaccines, obtaining consents, and reviewing risks and benefits. However, for each of the three residents cited, the medical records did not reflect that this process occurred for the COVID-19 vaccine at admission. At the exit conference on 3/26/2026 at 3:21 PM with the NHA, DON, and ADON, the surveyor shared concerns that these residents were not offered or did not receive a COVID-19 vaccination and that there was no corresponding documentation of education, administration, refusal, or contraindication in their records.
Failure to Complete Narcotic Count Signatures on All Shifts
Penalty
Summary
The facility failed to ensure that narcotic counts were properly initialed by two nurses on all three shifts at the change of shift for all six medication carts reviewed. According to the facility's policy, two nurses are required to count and verify the narcotic count at the start of each shift and sign the Narcotic Count Sheets. However, documentation review revealed multiple instances across all medication carts where either the counting nurse, the recording nurse, or both did not sign off to indicate the narcotic count was correct for various shifts and dates. Direct observations of the medication carts, along with interviews with nursing staff, confirmed that the narcotic count sheets were not consistently signed as required. Each nurse interviewed acknowledged that the sheets should have been signed during each shift change and verified that the required signatures were missing for their respective carts. The Director of Nursing also confirmed that the narcotic sheets were not signed off on each shift as per policy. No specific residents were identified as being directly affected in the report, and there is no mention of any adverse outcomes or medical history related to the residents. The deficiency centers on the facility's failure to follow its own policy for narcotic accountability, as evidenced by incomplete documentation and staff confirmation of the lapses.
Food Safety and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, potentially affecting all 74 residents who consume food prepared by the facility. Observations in the main kitchen revealed partially used and undated food items in the walk-in cooler, including tortilla shells and pie crusts that were open to the air. Additionally, the fourth-floor fridge contained opened and undated butter and a partially eaten item. The facility's policy on food safety requires that food be wrapped and dated after opening, but this was not adhered to, as confirmed by the Kitchen Manager. Furthermore, a scoop was improperly stored in a bin of sugar granules instead of being placed in its designated holder. The facility also lacked a policy on the use of hair restraints in the kitchen, which led to non-compliance with professional standards. Disposable hair nets and beard nets were available, but staff, including a maintenance employee and a cook with facial hair, were observed not wearing them while in the kitchen area. The cook was seen handling food without a hair or beard net, which is against food safety protocols. These deficiencies were discussed with the Nursing Home Administrator, Director of Nursing, and Director of Food Services, but no additional information was provided at the time.
Failure to Conduct Annual N95 Fit Testing for Staff
Penalty
Summary
The facility failed to ensure that 34 staff members received their annual N95 respirator fit testing, as required by their Covid-19 Respiratory Protection Program policy. The policy mandates that all employees who are required to wear respirators must pass an initial fit test and be fit-tested annually, or when there are changes in the employee's physical condition or when using a new make, model, or size of respirator. During the survey, it was found that several staff members, including those in direct care, environmental services, finance, kitchen, activity department, and plant operations, had overdue fit test dates. The deficiency was identified through interviews and record reviews conducted by the surveyor. The Director of Nursing (DON) acknowledged the issue and attempted to provide updated documentation, but the records still showed overdue fit test dates for many staff members. The Nursing Home Administrator (NHA) was informed of the concern but had no additional information to provide. The lack of timely fit testing for staff members who are potentially exposed to airborne hazards, such as SARS-CoV-2, indicates a lapse in the facility's infection prevention and control program.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that residents using psychotropic drugs had comprehensive assessments and that PRN orders were limited to 14 days, as required. For one resident, the signed consent for Trazodone had expired, and a quarterly sleep assessment was not completed. The resident, who was cognitively intact, had a history of dementia, anxiety, and insomnia. Despite the expired consent, the medication continued to be administered without a current signed consent, and the necessary sleep assessments were not conducted quarterly as required. Another resident was readmitted with diagnoses including ankylosing spondylitis, obstructive sleep apnea, and major depressive disorder. The PRN order for Trazodone did not include a stop date, and the medication was administered for more than 14 days without the required documentation or justification from the attending physician. The facility's failure to adhere to the policy regarding PRN psychotropic medications was noted, and the order was eventually discontinued after a consultation report recommended its discontinuation. A third resident, who was severely cognitively impaired and on hospice care, had a PRN order for Ativan without a stop date. The consulting pharmacist recommended evaluating the ongoing use of lorazepam, but the physician declined the recommendation without providing a rationale. The facility did not ensure compliance with the requirement to limit PRN orders to 14 days or provide documentation for an extended period, leading to the continuation of the medication without proper oversight.
Deficiency in Hospice Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for two residents, R9 and R43, who were receiving hospice care. For R9, who was admitted with chronic obstructive pulmonary disease, chronic kidney disease, and cognitive impairment, the facility did not have access to the necessary hospice documentation, including the hospice election statement, admissions agreement, and recertification orders. The only document available was a plan of care dated 9/4/24, despite R9 being placed on hospice on 8/3/24. The Health Information Clerk (HIC) responsible for maintaining hospice binders confirmed that the hospice company had not sent the required documentation, and the facility was in the process of obtaining it. Similarly, for R43, who was admitted with dementia and began hospice services on 12/19/2024, the facility lacked adequate communication and documentation from the hospice provider. The hospice binder for R43 contained only three documents: the order sheet, facility notification of admission, and the plan of care, with no dates for team visits filled out. Interviews with facility staff, including an LPN and RN Unit Manager, revealed that hospice staff did not utilize the hospice binder for communication, and no documentation was found in the electronic medical record. The lack of communication and documentation between the hospice providers and the facility staff led to deficiencies in coordinating care for both residents. Despite the facility's policy and hospice contract requiring collaboration and documentation, the necessary information was not available to the facility staff, hindering their ability to provide integrated hospice care. The surveyor's findings highlighted the communication gaps and the absence of required hospice documentation in the residents' medical records.
Medication Administration Error for Dialysis Patient
Penalty
Summary
The facility failed to administer medications as ordered for a resident, identified as R1, who was supposed to receive two tablets of Hydrocodone-Acetaminophen 5-325 mg before going to dialysis. On the morning of 10/2/24, R1 received only one tablet instead of the prescribed two. This discrepancy was due to a misinterpretation of the physician's orders by the nursing staff. The orders specified that R1 should receive one tablet every six hours as needed and an additional tablet on dialysis days, which was not followed. R1 has a complex medical history, including COPD, bilateral above-knee amputation, hypertension, congestive heart failure, diabetes mellitus, anxiety, depression, and end-stage renal disease. R1 is cognitively intact, as indicated by a BIMS score of 13, and experiences frequent pain, with a reported intensity of 8 on a scale of 0 to 10. The resident's care plan includes scheduled and PRN analgesics to manage pain, especially on dialysis days when pain management is crucial. The incident was brought to light through interviews and record reviews, revealing that the nursing staff, including LPN-D and LPN-E, misunderstood the medication orders. LPN-D administered only one tablet, believing that R1 could not receive another dose, and LPN-E confirmed this misunderstanding. The RN Manager and DON acknowledged the error, attributing it to a misreading of the orders, which led to R1 not receiving adequate pain management before dialysis.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by two separate incidents involving incorrect medication administration. The first incident occurred when the resident received a double dose of Clonazepam, a medication prescribed for anxiety, instead of the prescribed 0.5 mg dose. This error was attributed to the LPN pulling the medication from the wrong card, as both the 0.5 mg and 1 mg cards were placed next to each other. Despite the error being documented, there was no evidence of immediate monitoring of the resident's vital signs following the incident. The second incident involved the administration of Morphine, a medication not prescribed to the resident, instead of Clonazepam. This error occurred when the LPN, who was distracted by an ambulance picking up another resident, mistakenly administered Morphine. The resident, who had a history of heart failure, depression, schizoaffective disorder, anxiety, and respiratory failure, required close monitoring due to the potential for serious adverse reactions from Morphine, especially given the resident's existing medication regimen, which included drugs with known interactions with Morphine. The facility's policies on medication administration and error reporting were not adequately followed, as evidenced by the lack of immediate and thorough documentation and monitoring following the medication errors. The facility's failure to administer medications in accordance with prescribers' orders and professional standards resulted in the resident requiring intensive monitoring of vital signs and neurological status. The report highlights deficiencies in staff training and adherence to medication administration protocols, particularly concerning agency staff who were not provided with adequate orientation on the facility's policies.
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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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