Marquardt Memorial Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Watertown, Wisconsin.
- Location
- 1020 Hill St, Watertown, Wisconsin 53098
- CMS Provider Number
- 525543
- Inspections on file
- 32
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Marquardt Memorial Manor during CMS and state inspections, most recent first.
The facility failed to follow its grievance policy and thoroughly investigate or resolve multiple resident complaints. A resident with paraplegia and pressure injuries had a family member file a written grievance about a missed medical appointment, inadequate wound care supplies, incontinence care issues, and unreturned calls, but the grievance form was left incomplete and no investigation or follow-up occurred. Another resident with post-stroke hemiplegia, dependent on staff for showers, reported going weeks without showers and having a family member report this to the facility, yet no grievance documentation or investigation was found. A third resident with COPD, morbid obesity, PVD, and O2 dependence reported that an RN used profanity during a nighttime medication pass; although the resident told an RN and a CNA, and an LPN reported the concern to a supervisor, the facility did not log a grievance, document the event in the record, or complete an official investigation.
The facility failed to consistently provide scheduled showers/baths and honor bathing preferences for three dependent residents. One resident with hemiplegia and intact cognition had multiple missed weekly showers documented as blank entries on the MAR, and both the resident and a family member reported that showers were not provided as scheduled. A second resident with paraplegia and morbid obesity had orders for weekly skin checks and baths, but did not receive showers because the facility’s bariatric shower chair was nonfunctional and a replacement did not arrive until after discharge, with staff indicating that only bed baths could be given. A third resident with moderate cognitive impairment reported preferring showers but stated staff did not ask about preferences and instead provided bed baths. The DON and an LPN confirmed that MAR/TAR blanks indicate showers/baths were not completed and that refusals and reasons should be documented, showing that ordered bathing care and resident preferences were not consistently followed or recorded.
A resident with paraplegia, obesity, neurogenic bowel and bladder, and a history of sacral pressure injuries had a large unstageable coccyx DTI managed per APNP orders with cleansing, chamosyn cream, and no dressing, along with q2h repositioning and weekly skin checks. Despite this, an LPN independently applied 4 x 4 foam border adhesive dressings to an open buttocks area on multiple occasions without a provider order, while only sending a message to the provider and later finding no corresponding order in the record. Separately, the admission head-to-toe skin assessment by an RN did not identify a penile/scrotal pressure injury, which was later discovered and documented during a subsequent hospital stay, with hospital notes indicating the resident and family were previously unaware of that wound. The DON stated that all skin should be assessed on admission and that foam border dressings should not be used without an order.
A resident with paraplegia, neurogenic bladder, and other comorbidities was admitted with an indwelling urinary catheter that was scheduled to be replaced with a suprapubic catheter. The cognitively intact resident had a procedure appointment, but the facility did not ensure stretcher transport was properly requested and arranged, and only a last-minute phone request was made, which did not result in transport being secured. The facility lacked a written policy for scheduling appointments and transportation, and no electronic request for the original appointment date was found, causing the suprapubic catheter placement to be delayed and the procedure to be rescheduled.
A resident with COPD, morbid obesity, alveolar hypoventilation, history of pulmonary embolism, and dependence on supplemental O2 had an order for 2–4 L via nasal cannula to maintain SpO2 > 90%, with tubing changes as needed. An RN changed the resident’s oxygen tubing but did not turn the oxygen back on, and the resident’s attempts to summon staff using the call light and phone went unanswered. A CNA later found the oxygen off during morning rounds and turned it back on, confirming the resident’s report that the oxygen had been off for most of the night, while the regional nurse consultant was unaware the resident had been without oxygen.
A resident with multiple medical conditions and a history of a revoked POA was not provided with adequate support or opportunity to complete a new POA document, despite being unable to read or write and expressing a desire for assistance. Facility staff were unaware of the resident's illiteracy and did not take further action to fulfill the resident's request for a decision maker, contrary to facility policy and regulatory requirements.
A resident with intact cognition and significant medical needs reported that a CNA repeatedly called them "stupid" in front of other staff. The allegation was communicated to staff, but the social worker and DON were not promptly informed, and the required report to the State Agency was not made in accordance with facility policy.
An LPN and a CNA failed to wear required gowns and did not follow proper hand hygiene or disinfection procedures while providing wound care to a resident with a stage 4 pressure ulcer and indwelling devices. Supplies were placed on unclean surfaces, and the treatment cart and equipment were not properly disinfected before being used for other residents. Staff interviews confirmed lapses in following infection control policies, including PPE use and handling of wound care items.
Two residents did not receive adequate supervision or assistance devices to prevent accidents, resulting in one resident sustaining a major injury after a fall when care plan interventions were not followed, and another experiencing repeated falls without appropriate new interventions or root cause analysis. The facility failed to ensure care plans were implemented and did not individualize fall prevention strategies after multiple incidents.
A resident with respiratory symptoms and under droplet precautions had a sign posted requiring hand hygiene and mask use upon room entry. A CNA was observed entering the room twice without a mask or performing hand hygiene. Staff interviews revealed inconsistent understanding of droplet precaution protocols, and the NHA acknowledged that some staff, including managers, may not have followed the required infection control measures.
The facility failed to include necessary details in their assessment to care for residents with Substance Use Disorder (SUD), affecting nine residents with diagnoses such as alcohol abuse and dependence. The assessment did not evaluate the SUD population or address their specific needs, and the facility lacked policies, procedures, and staff training for SUD care. Interviews revealed staff had not received training on SUD care or medication interactions, and the Director of Nursing confirmed the absence of education and competencies for SUD care.
The facility failed to provide necessary behavioral health services for residents with substance use disorders (SUDs). A resident with a history of cocaine, alcohol, and cannabis use was frequently intoxicated, yet no comprehensive care plan or timely interventions were implemented. Another resident consumed significant amounts of alcohol daily without a care plan addressing his use. A third resident, admitted with alcohol use disorder, continued drinking without a care plan in place. The facility's lack of structured care plans for SUDs highlights a significant oversight.
A resident with multiple health issues, including a history of pressure injuries, developed unstageable pressure injuries due to the facility's failure to revise the care plan and monitor skin under a CAM boot. The facility did not conduct timely assessments, leading to the progression of the injuries.
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents. One resident experienced an unwitnessed fall, and their care plan was not updated. Later, they were improperly transferred, resulting in a fracture. Another resident's fall was not thoroughly investigated, with incomplete documentation and unclear supervision. These incidents highlight deficiencies in adherence to fall prevention policies and resident supervision.
The facility failed to maintain sanitary food preparation and service practices, as the dishwashing machine did not reach the required sanitizing temperature, and a cook did not follow proper hand hygiene protocols. The dishwashing machine consistently failed to reach the necessary 180 degrees Fahrenheit for sanitization, yet staff continued to use it. Additionally, a cook was observed handling food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands, violating facility policies. These deficiencies potentially affected all 76 residents.
A facility failed to conduct a comprehensive assessment and develop a plan of care for a resident using an abdominal binder as a physical restraint. The resident, with severe disabilities and a g-tube, had the binder in place at all times without evidence of it being the least restrictive option or documentation of ongoing re-evaluation. The facility lacked a policy on restraint use, and the binder's use was not documented in the resident's care plan.
The facility failed to complete neurological checks following unwitnessed falls for three residents, as per policy. A resident with alcohol-induced dementia had multiple falls, but checks were delayed until a nurse practitioner's order was received. Another resident experienced unwitnessed falls on several occasions, with discrepancies noted between handwritten and electronic records, indicating missed checks. Additionally, a resident at high fall risk due to hemiplegia and dementia had an unwitnessed fall, with significant gaps in the required neurological evaluations.
A facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease by not assessing the resident's AV fistula for adequate blood flow. Despite the facility's policy requiring coordination with the dialysis center, staff did not routinely check the access site, and there was no evidence of documented assessments. The resident reported that staff rarely looked at the site, and the ADON confirmed the lack of consistent monitoring.
A resident's medical record lacked documentation regarding the offering, receipt, or declination of a Pneumococcal immunization, contrary to the facility's policy. The ADON admitted that the resident's immunization status was not addressed upon admission and was not included in the monthly audit. The deficiency was identified during a surveyor's review, highlighting a gap in the facility's immunization documentation process.
A facility failed to document a resident's COVID-19 immunization status, as required by its policy. The resident's electronic medical record lacked information on whether the vaccine was offered, received, or declined. The ADON admitted the oversight, noting that the resident was not included in the monthly immunization audit and had not been offered the vaccine. The facility's admission process for immunizations was still being developed.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to thoroughly investigate and resolve grievances for three cognitively intact residents. For one resident with complete paraplegia, type 2 diabetes, class 3 obesity, neurogenic bowel and bladder, and pressure injuries, a family member submitted a written grievance on 1/7/26 regarding a missed suprapubic catheter placement appointment due to unscheduled transport, worsening of an existing pressure injury and discovery of another pressure injury in the hospital, lack of appropriate wound care supplies, repeated observations of the resident in a soiled brief with stool dripping on the floor, and unreturned phone calls from staff. The grievance form in the facility’s file was incomplete, and the Registered Nurse Consultant confirmed that although the concerns were reported, the facility did not complete an investigation or follow-up on the grievance. Another resident with hemiplegia and hemiparesis following a stroke, who was dependent on staff for showers and had intact cognition, reported filing a grievance in September 2025 about not receiving a shower for three weeks. The resident did not recall anyone following up about the concern and stated that a family member who worked at the facility reported the missing showers to the facility. The family member confirmed reporting that the resident was not receiving showers and that the resident’s showers resumed afterward, but did not recall whether an investigation occurred. When surveyors requested documentation of a grievance related to this issue, facility leadership could not produce any grievance documentation or investigation related to the resident’s shower complaints. A third resident, who had COPD, morbid obesity, peripheral vascular disease, a history of pulmonary embolism, and dependence on supplemental oxygen and staff assistance for most ADLs, reported that on a night in January 2026, an RN attempted to administer medication with a spoon without acknowledging the resident’s ability to self-feed and need for oxygen tubing change. The resident stated that when the RN returned later and again attempted to give medication, the RN said, “I’m not going to take your shit,” then changed the oxygen tubing and left. The resident reported this incident to an RN and a CNA on the following morning shift. Both staff members confirmed the resident’s report and stated they relayed the concern to a nurse or supervisor, and an LPN acknowledged being told the resident believed the RN had sworn at them and reported it to a supervisor. The RN Consultant confirmed the concern was reported but stated the facility did not complete an official investigation or file a grievance, and there was no related progress note in the resident’s record.
Failure to Provide Scheduled Showers and Honor Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or baths and to honor bathing preferences for three residents who required staff assistance with activities of daily living. One resident with hemiplegia and intact cognition was dependent on staff for showers and was scheduled for a weekly bath on Tuesdays. Review of the Medication Administration Record (MAR) showed multiple Tuesdays over several months with blank documentation for the ordered weekly skin check and bath, and the facility could not produce complete bath schedules for parts of November and December. The resident reported wanting showers, stated they had not received showers on recent scheduled days, and denied refusing showers, while a family member confirmed the resident had complained about not receiving showers, particularly in November and December. Another resident with complete paraplegia, obesity class 3, neurogenic bowel and bladder, and intact cognition had an order for a weekly skin check and bath according to the shower schedule. The Treatment Administration Record (TAR) showed the order documented as completed on three dates, but the facility did not have a functioning bariatric shower chair during the resident’s stay. The scheduler/central supply staff member stated a bariatric shower chair was ordered the day before admission after being informed of the need, that the existing bariatric chair was found to be nonfunctional and could not be repaired by maintenance, and that the replacement chair did not arrive until after the resident was discharged. An RN stated that the resident’s scheduled “shower” would have been provided as a bed bath due to the lack of a working bariatric shower chair. A third resident with moderate cognitive impairment and an activated POA was dependent on staff for bathing and expressed a clear preference for showers over bed baths. The resident reported that staff did not ask about bathing preference and instead provided bed baths, stating they wanted only showers and were bothered by not receiving them. The DON stated that showers and baths are documented on the MAR or TAR, that refusals and reasons should be documented, and that blanks should not be left because they indicate a shower or bath was not completed. The DON and an LPN both indicated that a checked MAR/TAR entry signifies that a shower/bath and skin check were completed, and that blank entries mean the care was not done, confirming that scheduled showers/baths and resident preferences were not consistently honored or documented for these residents.
Failure to Follow Wound Orders and Identify All Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent pressure injuries from developing and to promote healing of existing wounds for one resident. The facility had a Pressure Injury Prevention and Managing Skin Integrity policy requiring Braden Scale risk assessments, comprehensive skin checks on admission and weekly, identification and care planning of skin breakdown, and collaboration with the IDT and providers for abnormal skin findings. The policy also required weekly wound rounds, provider notification of wound decline, and adherence to ordered interventions. Despite these requirements, the facility did not consistently follow its own policy or ensure that wound treatments were based on provider orders. The resident was admitted with multiple significant conditions, including complete paraplegia, type 2 diabetes, morbid obesity, neurogenic bowel and bladder, and a history of sacral pressure injuries. On admission, an RN documented a stage 2 coccyx pressure injury and coccyx bruising, and later a left gluteal MASD, with subsequent development of an unstageable coccyx deep tissue injury. Wound assessments documented a large sacral/coccyx area with deep purple discoloration and scattered open areas, and an APNP ordered cleansing with soap and water, application of chamosyn cream twice daily, aggressive offloading, and specifically indicated not to cover the wound with a dressing. Facility orders reflected these directions, including repositioning every two hours and weekly skin checks. However, the facility’s documentation did not show any wound orders on the hospital discharge summary at admission, and the facility relied on its own wound team and internal assessments to manage the coccyx wound. An LPN reported that, on a weekend, after noticing what appeared to be an open area on the resident’s buttocks, the LPN applied 4 x 4 foam border adhesive dressings and barrier cream multiple times due to the resident’s frequent loose stools causing dressings to come off. The LPN stated they sent a message to the provider when the open area was noticed but could not locate any provider order in the medical record authorizing the use of foam border dressings during the period they were applied. The DON later stated that staff should not apply foam border dressings without an order and that the provider should have been informed as soon as the wound was identified. Additionally, a separate pressure injury on the resident’s penile/scrotal area was not identified by facility staff during the admission head-to-toe skin assessment and was instead discovered later at the hospital, where documentation indicated the resident and family were not aware of this wound until that hospitalization. The DON confirmed that admission skin assessments should include viewing all skin areas, and the RN who performed the admission assessment stated that if a penile pressure injury had been seen, it would have been documented, indicating that this wound was not identified by the facility prior to the hospital finding it.
Failure to Arrange Timely Transportation for Suprapubic Catheter Placement
Penalty
Summary
The facility failed to ensure timely placement of a suprapubic catheter for one resident when transportation was not secured for a scheduled medical appointment. The resident had multiple diagnoses including complete paraplegia, type 2 diabetes mellitus, anxiety, class 3 obesity, neuromuscular dysfunction of the bladder, and neurogenic bowel, and was admitted with an indwelling urinary catheter that was to be replaced with a suprapubic catheter. The resident was cognitively intact, with a BIMS score of 15, and was their own decision maker. A grievance documented that the resident was scheduled for suprapubic catheter insertion on 12/31/25, but the facility did not ensure stretcher transportation was arranged as requested by a family member, resulting in the need to reschedule the procedure. The surveyor’s review of the medical record and interviews with the Scheduling Coordinator revealed that transportation requests are made through the facility’s electronic medical record system and then processed by the Scheduling Coordinator or a backup staff member. The facility did not have a written policy or procedure for appointments and transportation. Initial review showed no appointment or transportation request entered for the resident’s 12/31/25 procedure. Further review identified only a last-minute call from staff to the Scheduling Coordinator’s coworker requesting stretcher transport for that date, and the facility was unable to secure stretcher transport on short notice. As a result, the resident’s appointment for suprapubic catheter placement had to be rescheduled to 1/5/26.
Failure to Restart Oxygen After Tubing Change
Penalty
Summary
The facility failed to ensure that a resident dependent on supplemental oxygen received ordered oxygen therapy following a tubing change. The resident had multiple respiratory-related diagnoses, including COPD, morbid obesity, alveolar hypoventilation, a history of pulmonary embolism, and was ordered to receive 2–4 L oxygen via nasal cannula to maintain oxygen saturation above 90%, with tubing to be changed and dated every 7 days and as needed. The facility’s Standard Respiratory Protocol directed RNs to apply oxygen as ordered for individuals with impaired or potential impairment of gas exchange. On the night of 1/9/26, an RN changed the resident’s oxygen tubing but did not turn the oxygen back on afterward. Following the tubing change, the resident reported turning on the call light and calling the nurses’ station, but stated that no one answered. The resident, who was cognitively intact and their own decision maker, stated that a CNA discovered in the morning that the oxygen was off and then turned it back on. The CNA confirmed that, upon checking the resident that morning, the oxygen was not on and that the resident reported the RN had changed the tubing without restarting the oxygen, resulting in the resident being without oxygen for most of the night, approximately six hours. The Regional Nurse Consultant stated they were not aware that the resident had gone without oxygen.
Failure to Provide Support for Advance Directive Completion
Penalty
Summary
The facility failed to ensure that a resident was provided with an opportunity to create a Power of Attorney (POA) document or designate an alternate decision maker in the event of incapacity, as required by facility policy and the Patient Self Determination Act. Upon admission, the resident, who had multiple complex medical diagnoses including spina bifida, paraplegia, and a stage 4 pressure ulcer, was not offered adequate support to complete a POA document despite expressing discomfort with making healthcare decisions and being unable to read or write. The resident reported that a previous POA designation had been revoked by Adult Protective Services (APS) and expressed a desire for a new POA or Guardian to assist with decision-making. Staff interviews revealed that the social worker was unaware of the resident's illiteracy and was uncertain about the existence of a current POA document. Attempts to obtain information from APS were unsuccessful, and APS confirmed that the resident was their own decision maker and entitled to complete a new POA if desired. Despite the resident's request and the facility's policy to discuss and verify advanced care planning upon admission and at care conferences, no further action was taken by the facility to assist the resident in completing a new POA document.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
An allegation of verbal abuse was made by a resident with intact cognition and multiple medical conditions, including spina bifida, paraplegia, and a stage 4 pressure ulcer. The resident reported to staff that a CNA repeatedly addressed them as "stupid" in the presence of other staff members. The resident informed an unidentified staff member about the name-calling, who stated they would notify the social worker and ensure the CNA did not work with the resident that day. However, the social worker was not made aware of the allegation until later, and the Director of Nursing was also not informed until the day of the surveyor's investigation. The facility's policy requires that all allegations of abuse be reported to the State Agency immediately, or within specific timeframes depending on the severity. Despite this, the allegation was not reported to the State Agency as required. The staff member who initially received the report relayed the information to the Director of Nursing, but there was a delay in both internal and external reporting. The correct CNA was only identified and suspended after the surveyor's involvement, indicating a failure to follow the facility's abuse reporting protocol.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during wound care for a resident with significant medical needs, including a stage 4 pressure ulcer and indwelling medical devices. During the observed wound care procedure, both an LPN and a CNA entered the resident's room without donning gowns, despite signage indicating Enhanced Barrier Precautions (EBP) were required. The LPN brought a treatment cart into the room, placed wound care supplies directly on the bedside table without disinfecting the surface or using a barrier, and both staff members wore only gloves during the procedure. Their clothing came into contact with the resident's environment, including bed linens, increasing the risk of cross-contamination. Throughout the wound care process, the LPN did not consistently perform hand hygiene at required moments, such as after glove removal and before handling clean supplies. The LPN also handled wound care items and the resident's environment with bare hands at times, and placed unused dressing packages and clean gloves on potentially contaminated surfaces. After completing care, the LPN returned the treatment cart to the nurses' station and began disinfecting equipment, but did not observe the required dwell time for the disinfectant before placing items back into the cart, further compromising infection control. Interviews with the LPN, CNA, and Director of Nursing confirmed a lack of adherence to the facility's policies regarding PPE use, hand hygiene, and the handling of wound care supplies. The LPN and CNA acknowledged forgetting to wear gowns, and the LPN was unaware of the proper use of disinfectant products. The Director of Nursing verified that gowns should have been worn, supplies should have been handled with barriers, and items used in the resident's room should not be used for other residents. These failures resulted in a breakdown of the infection prevention and control program as required by facility policy.
Failure to Prevent Accidents and Implement Effective Fall Interventions
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, resulting in one resident experiencing actual harm. One resident, who had multiple diagnoses including stroke, muscle weakness, and moderate cognitive impairment, was assessed as a moderate fall risk and required two staff for transfers with a Hoyer lift, as well as specific interventions such as keeping the bed against the wall and the call light within reach. Despite these documented interventions, the resident experienced a fall with major injury when a CNA attempted to reposition the resident alone, rolling the resident away from himself, which led to the resident falling to the floor and sustaining a right hip fracture. At the time of surveyor observation, the resident's bed was not against the wall and the call light was on the ground, not within reach, contrary to the care plan requirements. Another resident with diagnoses including dementia and a history of falls experienced twelve falls over a period of time. The care plan included standard fall prevention interventions such as offering toileting every two hours, ensuring the call light was within reach, and not leaving the resident unattended while awake. However, after each fall, the facility either failed to add new interventions to the care plan or only added interventions that were already considered standard practice, such as offering toileting at certain times. The facility did not complete a root cause analysis for any of the falls, including those resulting in injury, and did not implement individualized or effective interventions to address the repeated falls. Interviews with the DON confirmed that root cause analyses were not performed unless there was an injury, and that interventions added after falls were often not new or specific to the resident's needs. The interdisciplinary team reviewed falls in morning meetings, but did not identify or address the lack of new interventions for the resident with repeated falls. The facility's failure to follow care plans, ensure required safety devices were in place, and implement appropriate interventions after falls led to continued risk and actual harm for the residents involved.
Failure to Adhere to Droplet Precaution Protocols for Resident on Isolation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to droplet precaution protocols for a resident who was under isolation. The resident, who had a recent history of respiratory symptoms including cough, nasal congestion, fever, and was being treated for pneumonia and pleural effusion, had a droplet precaution sign posted on the door. The sign instructed all individuals to perform hand hygiene upon entering and exiting the room and to wear a mask when entering. Despite these clear instructions, a Certified Nursing Assistant (CNA) was observed entering the resident's room on two separate occasions without wearing a mask or performing hand hygiene. Interviews with various staff members, including LPNs, CNAs, a Med Tech, the DON, and the Nursing Home Administrator, revealed inconsistent understanding and application of droplet precaution protocols. Some staff believed that precautions were only necessary when providing direct care, while others stated that PPE and hand hygiene were required every time anyone entered the room. The Nursing Home Administrator acknowledged that extra staff, including managers, may have entered the room without following the required precautions, especially during meal delivery. The administrator also noted confusion among staff due to the frequency and variety of precaution signs, which may have contributed to the failure to consistently implement infection control measures as outlined in the facility's policy.
Deficiency in Facility-Wide Assessment for SUD Care
Penalty
Summary
The facility failed to ensure that their facility-wide assessment included all necessary details to provide adequate care for residents with Substance Use Disorder (SUD). This deficiency potentially affects nine residents with SUD diagnoses, including conditions such as alcohol abuse, alcohol dependence, and cannabis use. The facility's assessment did not evaluate the SUD resident population or address their specific physical and behavioral health needs. Additionally, the facility's admission capabilities did not list SUD as a condition they are equipped to manage, and SUD was not included in the resident population characteristics or conditions. The facility lacked policies and procedures for the care of residents with SUD, and there was no education, training, or competencies provided to staff regarding the care of these residents. Interviews with staff, including an LPN and an RN, revealed that they had not received training or completed competencies related to SUD care, including knowledge of medication interactions with alcohol. The Director of Nursing confirmed the absence of education and training for staff on SUD, withdrawal symptoms, or overdoses, and acknowledged that there was no assessment for residents under the influence of substances. The facility's failure to evaluate and address the needs of the SUD resident population, along with the lack of staff training and competencies, indicates a significant oversight in their facility-wide assessment. This deficiency highlights the facility's inability to provide appropriate care and services to residents with SUD, potentially compromising their health and safety.
Failure to Address Substance Use Disorders in Residents
Penalty
Summary
The facility failed to provide necessary behavioral health services to ensure residents received the highest practicable mental and psychosocial well-being, specifically in addressing substance use disorders (SUDs). Three residents, identified as R1, R4, and R5, were not provided with comprehensive assessments or person-centered care plans to address their SUDs. R1, who had a history of cocaine, alcohol, and cannabis use, was frequently intoxicated within the facility, yet no comprehensive care plan or timely interventions were implemented to address his SUD. Despite being aware of R1's alcohol use, the facility delayed implementing monitoring orders and failed to provide timely AODA/mental health referrals. R5, who regularly consumed alcohol, was allowed to have alcohol stored in a safe and consumed independently, yet there was no care plan addressing his alcohol use. Staff interviews revealed that R5 consumed a significant amount of vodka daily, and although staff were aware of his alcohol consumption, no interventions were documented in his care plan. The facility's lack of a structured approach to managing R5's alcohol use highlights a significant oversight in addressing his SUD. R4, admitted with a diagnosis of alcohol use disorder, had experienced alcohol withdrawal during a prior hospitalization. Despite this, the facility did not develop a care plan to address his alcohol use. Provider notes documented R4's continued alcohol use within the facility, yet the Director of Nursing was unaware of his drinking, indicating a communication breakdown and failure to review provider notes. The facility's inaction in creating and implementing care plans for residents with SUDs demonstrates a significant deficiency in providing necessary behavioral health services.
Failure to Monitor and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement appropriate interventions for a resident, R24, who was at risk for pressure injuries and had a history of such injuries. R24 was admitted with multiple diagnoses, including End Stage Renal Disease, Peripheral Vascular Disease, and a history of pressure injuries. Despite being at risk, the facility did not revise the care plan to include increased monitoring of the skin under a Controlled Ankle Movement (CAM) boot, which was applied for an ankle fracture. The boot was ordered to be worn at all times except for hygiene and icing, yet the care plan did not reflect this need for increased vigilance. R24 developed unstageable pressure injuries on the left heel and top of the foot, which were not identified in a timely manner. The facility's documentation indicated that the pressure injury was present as early as October 5, 2023, but a comprehensive assessment was not completed until October 11, 2023. The facility's wound care follow-up noted the presence of a new area on the dorsal aspect of the left foot and an unstageable pressure injury on the left heel. However, the documentation was inconsistent, as a subsequent assessment incorrectly staged the dorsal foot pressure injury. The facility's failure to revise the care plan and conduct timely assessments contributed to the development and progression of R24's pressure injuries. Despite being followed by the facility wound nurse and an Advanced Practice Nurse Practitioner, the wounds failed to heal, and further testing revealed critical lower limb ischemia. The lack of comprehensive assessment and care plan revisions for the CAM boot and pressure injury risk factors were significant deficiencies in the care provided to R24.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R10 and R222. R10 experienced an unwitnessed fall on November 25, 2023, and the facility did not complete neurological checks as scheduled per their policy. Additionally, R10's Fall Risk Care Plan was not updated after the fall. On January 19, 2024, R10 was transferred by a CNA using a Sara Steady without the assistance of another staff member, contrary to the care plan that required two assists. This resulted in R10 falling and fracturing their left tibia, leading to hospitalization. R222 had a fall on June 6, 2024, which the facility did not thoroughly investigate. The fall occurred when R222 was found on the floor with complaints of neck and knee pain. The facility's documentation was incomplete, lacking details such as the time of the fall, the last wellness check, and the last time the resident was toileted. Staff interviews revealed inconsistencies in the account of events, and it was unclear how long R222 had been on the floor before being discovered. The facility's failure to conduct a thorough investigation and document critical information contributed to the deficiency. Both incidents highlight the facility's failure to adhere to its policies regarding fall prevention and resident supervision. The lack of proper training and adherence to care plans, as well as inadequate investigation and documentation of incidents, were significant factors leading to the deficiencies identified by the surveyors.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as evidenced by improper dishwashing practices and inadequate hand hygiene by kitchen staff. The dishwashing machine was observed to not reach the required sanitizing temperature of 180 degrees Fahrenheit during the rinse cycle, with recorded temperatures ranging from 150 to 167 degrees Fahrenheit. Despite this, staff continued to use the machine to wash and sanitize dishware, potentially affecting all 76 residents in the facility. The facility's policy required dishwashing staff to monitor and record dish machine temperatures and report any issues to the food service manager, but these procedures were not effectively followed. Additionally, the facility's cook was observed handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. The cook was seen touching various surfaces, such as the microwave and their own nose, and then handling food items without changing gloves or washing hands. This practice was in direct violation of the facility's handwashing and glove use policies, which required staff to wash hands before donning gloves and after engaging in activities that contaminate hands. The surveyor informed the facility's management, including the Assistant Director of Nursing, Nursing Home Administrator, and Regional Consultant, about the concerns with the dishwashing machine and hand hygiene practices. However, no additional information or corrective actions were provided at the time of the survey. The facility's failure to adhere to its own policies and procedures for food safety and sanitation posed a risk to the health and safety of its residents.
Failure to Assess and Plan for Physical Restraint Use
Penalty
Summary
The facility failed to ensure that a comprehensive assessment and a plan of care were developed for the continued use of a physical restraint on a resident. The resident, who has spastic quadriplegic cerebral palsy, severe intellectual disabilities, and dysphagia, was observed with an abdominal binder in place at all times. This binder, which the resident could not easily remove, restricted the resident's freedom of movement and access to their body. The facility did not provide evidence that the abdominal binder was the least restrictive alternative, nor did they document ongoing re-evaluation of its necessity. The facility's records showed that the abdominal binder was initially ordered to prevent the resident from pulling out their g-tube during times of agitation. However, a subsequent order required the binder to be worn at all times, without a documented assessment or plan of care addressing its use. The facility's Minimum Data Set did not document the use of restraints for the resident, and the Nursing Home Administrator did not consider the binder a restraint, despite its restrictive nature. Additionally, the facility lacked a policy on restraint use, and the resident's plan of care did not adequately document the rationale, duration, or alternative interventions for the binder's use.
Failure to Complete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed following unwitnessed falls for three residents, as per the facility's policy. Resident R35, who was admitted with a primary diagnosis of alcohol dependence with alcohol-induced persisting dementia, experienced multiple falls on 9/10/2024. Despite being found with red marks on the head, neurological checks were not completed until an order was received from the nurse practitioner, several hours after the initial fall. The facility's policy required immediate and regular neurological checks following such incidents, but these were not adhered to. Resident R66 also experienced unwitnessed falls on multiple occasions, specifically on 8/5/2024, 8/17/2024, and 8/22/2024. In each instance, the scheduled neurological checks were not fully completed as required by the facility's policy. The surveyor noted discrepancies between the handwritten forms and the electronic health records, indicating that several checks were missed, which compromised the monitoring of the resident's condition post-fall. Additionally, Resident R10, who was at high risk for falls due to multiple health conditions including hemiplegia and dementia, had an unwitnessed fall on 11/25/2023. The facility's staff failed to complete the required neurological checks, missing a significant number of scheduled evaluations. This lapse in protocol was confirmed through interviews with facility staff, who acknowledged the gaps in documentation and adherence to the neurological check policy.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. The resident, who has End Stage Renal Disease and other significant health conditions, was not properly monitored for complications related to their dialysis treatment. Specifically, the facility did not implement necessary interventions to assess and document the care of the resident's arteriovenous (AV) fistula, which is crucial for ensuring adequate blood flow during dialysis. The facility's policy required coordination and communication between the skilled nursing facility staff and the dialysis center, but this was not adequately reflected in the resident's care plan or records. Interviews and record reviews revealed that the staff did not routinely assess the resident's AV fistula for pulse, bruit, and thrill, which are essential indicators of proper blood flow. The resident reported that staff rarely checked the access site, and the Assistant Director of Nursing (ADON) confirmed that there was no consistent assessment upon the resident's return from dialysis. The surveyor found no evidence of documented assessments of the AV fistula, indicating a lack of adherence to the facility's dialysis policy and procedure, which contributed to the deficiency.
Lack of Documentation for Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that the medical records of a resident contained documentation related to Pneumococcal immunizations. The resident, who was admitted to the facility, did not have any record in their electronic medical record (EMR) indicating whether they were offered, received, or declined the Pneumococcal immunization. The facility's policy on infection control and individual immunizations requires that prophylactic immunizations be offered and documented in the EMR, but this was not adhered to in the case of the resident. The Assistant Director of Nursing (ADON) acknowledged that the resident's immunization record was not addressed upon admission and was not included in the monthly immunization audit. The ADON stated that the resident was not present during the last audit and had not been offered the Pneumonia immunization. It was also noted that the facility had not yet implemented a process to address resident immunizations upon admission, although efforts were underway to improve this with the hiring of new supervisors. The deficiency was identified during a surveyor's review, and no additional information was provided to explain the lack of documentation in the resident's medical record.
Failure to Document COVID-19 Immunization Status
Penalty
Summary
The facility failed to ensure that the medical records of a resident, identified as R67, contained documentation related to COVID-19 immunizations. Upon review, it was found that R67's electronic medical record did not indicate whether the resident was offered, received, or declined the COVID-19 vaccine. The facility's policy on infection control and individual immunizations mandates that prophylactic immunizations be offered and documented in the electronic medical record. However, this was not adhered to in the case of R67, who was admitted to the facility without having their immunization status verified or documented. During an interview, the Assistant Director of Nursing (ADON) acknowledged that R67's immunization record was not included in the monthly audit of resident immunizations, which encompasses COVID-19 vaccinations. The ADON admitted that R67 was not present during the last audit and had not been offered the COVID-19 vaccine. Furthermore, the ADON revealed that the facility's process for addressing resident immunizations upon admission was still under development, with new supervisory staff being hired to assist with this process. The deficiency was only addressed after the surveyor highlighted the issue, indicating a lapse in the facility's adherence to its own immunization policy.
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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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