Mulder Health Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in West Salem, Wisconsin.
- Location
- 713 Leonard St N, West Salem, Wisconsin 54669
- CMS Provider Number
- 525209
- Inspections on file
- 31
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Mulder Health Care Facility during CMS and state inspections, most recent first.
Multiple cognitively intact residents with conditions such as heart disease, morbid obesity, chronic kidney disease, and prior stroke reported that cash amounts ranging from about $50 to $75 went missing from their wallets and rooms, and each identified a CNA as the suspected individual. These residents described incidents occurring over weeks to months, including one resident awakening to find the CNA taking money from her wallet. Review of the EMR and progress notes for each resident over extended periods showed no documentation of their allegations, despite an abuse prevention policy that defines misappropriation of resident property and states residents have the right to be free from abuse and misappropriation, with ongoing oversight and supervision of staff to ensure policies are implemented.
Surveyors found that the facility did not follow its dietician-approved menus, repeatedly serving meals that omitted or substituted listed items such as French fries, vegetables, bananas, and condiments without appropriate, approved substitutions. Staff reported routinely changing menus based on supply and ordering issues and relying on a whiteboard menu marked as subject to change, while residents stated they were not given the actual menu, were unaware of planned items they would have preferred, and were not informed of alternates. In one case, a resident with dementia, kidney disease, and a care plan for a soft, bite-sized diet at risk for weight loss was served whole bread and whole grapes, received no potatoes, and ate independently without the indirect supervision and texture modifications specified in her orders and care plan.
Dietary staff failed to follow proper food handling practices while preparing and serving meals for all residents. A cook was observed taking temperatures of chili with beans, mashed potatoes, and pureed mixed vegetables while touching the inside of the food containers with a bare hand. A dietary aide was observed touching the inside of lids with bare hands while placing them on bowls of chili with beans and then placing these bowls on resident trays. The cook later acknowledged she was not supposed to touch the inside of food containers when taking temperatures, and the dietary aide reported she did not know if she should touch the inside of lids. The dietary manager confirmed staff were not supposed to touch the inside of containers or lids with bare hands during these tasks.
A resident with dementia, kidney disease, and a wound requiring nutritional support was admitted on a regular chopped, soft and bite-sized diet with thin liquids, ordered weekly weights, bedtime snacks, and ProStat twice daily. The care plan and initial nutritional assessment identified the resident as underweight and at risk for significant weight loss, with instructions to monitor intake and weight trends. However, staff failed to document 10 of 46 meals, did not record any weights after an early post-admission entry despite weekly weight orders, and did not show evidence of follow-up on the resident’s documented weight loss. The DON confirmed that weights and meal intake were not consistently documented, contrary to facility policies requiring regular weight monitoring and recording of meal intake percentages.
A facility failed to remove a CNA from resident care duties after an allegation of abuse was made by a resident, despite policy requiring immediate removal and suspension pending investigation. The resident, who was alert and oriented, reported being treated aggressively and physically grabbed by the CNA, with these actions corroborated by other staff. The CNA continued to work additional shifts and had potential contact with other residents during the ongoing investigation.
A resident with multiple medical conditions was subjected to abusive behavior by a CNA, who spoke in a condescending manner, grabbed the resident's wrist tightly without releasing when asked, and yelled in close proximity to the resident's face. The incident was witnessed by another CNA and an LPN, who observed the resident visibly upset and slight redness on the wrist. The event was reported for investigation.
A resident reported being spoken to in an abusive manner and having her wrist grabbed tightly by a CNA, with multiple staff witnessing the incident and noting the resident's distress. Although the event was promptly reported internally, the facility failed to notify the State Survey Agency within the required 24-hour timeframe, resulting in a deficiency for delayed reporting of alleged abuse.
A resident with significant mobility impairments was transferred to the bathroom using an EZ stand when their right arm was bumped against a door frame by CNA staff. The incident was not reported to the charge nurse or documented in the medical record, despite facility policy requiring immediate reporting and communication of all incidents. The DON confirmed the failure to follow protocol after the resident later reported severe pain.
A resident with multiple complex medical conditions, including dysphagia and chronic kidney disease, did not receive adequate daily fluid intake due to the facility's failure to total and assess fluid intake, monitor for dehydration, perform timely weight checks, and update care plans. This led to significant weight loss and repeated hospitalizations for dehydration and aspiration pneumonia, with staff interviews confirming confusion and lack of accountability for monitoring hydration.
A resident who required extensive assistance for toileting due to recent surgery and mobility limitations requested help to use the bathroom but was told by a CNA to wait based on an incorrect toileting schedule. The resident waited approximately 1 hour and 20 minutes before being assisted, during which time staff did not check on her or provide timely care, despite facility policy requiring person-centered and prompt assistance with ADLs.
A resident with a history of serious health conditions experienced a significant drop in oxygen saturation and pulse rate, requiring immediate physician notification. The facility failed to document or communicate this change to the physician, resulting in a deficiency in care. Despite temporary improvement with oxygen therapy, the lack of proper notification and documentation led to inadequate management of the resident's condition.
A resident with a history of cerebral infarction and hemiplegia suffered second-degree burns from hot soup due to inadequate supervision during meals. The facility failed to adhere to its policy of serving hot liquids at safe temperatures, resulting in immediate jeopardy. Staff interviews revealed inconsistencies in supervision responsibilities and a lack of adherence to temperature guidelines.
A facility failed to thoroughly investigate a resident-to-resident altercation involving a cognitively impaired resident who hit another resident. Despite the facility's policy requiring interviews with all involved persons, only the two residents directly involved were interviewed, as the incident was deemed isolated. This led to a deficiency in the investigation process.
Failure to Protect Cognitively Intact Residents From Misappropriation of Funds by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from misappropriation of their money by a staff member, CNA1. One resident reported waking from sleep to find CNA1 in her room taking money from her wallet. This resident had diagnoses including adult failure to thrive and heart disease and had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. Her electronic medical record, including progress notes from early August through mid-December, contained no documentation of her allegation of misappropriation of property. During the facility’s investigation into this initial allegation, three additional cognitively intact residents reported missing money and identified CNA1 as the suspected individual. One resident with morbid obesity and heart disease stated that $55 to $75 was taken from her wallet within the first few weeks after admission; her progress notes over several months contained no entries related to this allegation. Another resident with congestive heart failure and chronic kidney disease reported that $50 to $65 had been stolen from her in May, and she stated that “that lady” (CNA1) stole her money; again, her progress notes over many months did not reflect this allegation. A fourth resident with a history of stroke reported that money had gone missing “a while ago,” believed CNA1 took it, and later stated the money had been taken almost a year earlier; her progress notes similarly contained no documentation of the misappropriation allegation. The Administrator and DON confirmed to surveyors that the facility’s investigation into the reports from these four residents led them to conclude that CNA1 likely stole the residents’ money. The facility’s Abuse Prevention Program Policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of residents’ belongings or money without consent, and stated that each resident has the right to be free from abuse, neglect, and misappropriation, and that the facility would provide a safe environment and protect residents from abuse. The policy also stated that training on abuse prohibition alone does not relieve the facility of responsibility to assure residents are free from abuse and that the facility would provide ongoing oversight and supervision of staff to ensure policies are implemented as written. Despite these policy provisions, multiple residents reported missing money associated with CNA1, and their records lacked documentation of these allegations in the progress notes.
Failure to Follow Dietician-Approved Menus and Provide Ordered Diet Textures and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned menus and ensure meals met residents’ nutritional needs and preferences as written and approved. Surveyors reviewed the facility’s week three menus and observed multiple meals where items listed on the menu were not served. For one dinner, the posted menu included minestrone soup, grilled cheese, French fries, lettuce, tomato, onion, apple slices, ketchup, margarine, and 2% milk and/or coffee, but residents actually received minestrone soup, grilled cheese, canned pears, and a choice of 2% milk, coffee, or juice, with no French fries, lettuce, tomato, onion, or apples provided. For a lunch meal, the menu listed chili with beans, baked potato, sweet potato cornbread, red grapes, sour cream and chives, margarine, and 2% milk, coffee, or tea, but residents received chili with beans, baby baked potatoes, sweet potato cornbread or a dinner roll, red grapes, and beverages, with no sour cream and chives served. For a supper meal, the menu listed corn dogs, creamy coleslaw, banana, margarine, and beverages, but residents received corn dogs, tater tots, coleslaw, sugar cookies, and beverages, with no banana served. Staff interviews confirmed that menus were routinely altered without adherence to the written, dietician-approved menu and without appropriate substitutions being reviewed. A cook reported that the facility did not usually order regular baking potatoes because of their size and instead used baby baked potatoes, and that sour cream and chives were usually not included. The Administrator stated that the facility relied on a whiteboard as the working menu and that it was labeled as subject to change. The Dietary Manager stated that menu items varied based on supply and ordering issues and acknowledged being unaware that a registered dietician needed to approve menu adjustments to ensure residents received appropriate amounts and types of food within the same food groups. Residents in a group interview reported they were not provided with the actual facility menu, only what was written on the dry erase board, and that alternates were not posted. They stated they were unaware that French fries and lettuce, tomato, onion, and ketchup were supposed to be part of a prior dinner meal, expressed that they liked French fries and would have wanted them, and noted that pears were served frequently and that no alternate fruit was offered when they did not like pears. The deficiency also included failure to provide an individual resident with meals consistent with her ordered diet texture, care plan, and preferences. One resident with dementia, chronic and acute kidney disease, cellulitis, and a severely impaired BIMS score was care planned as being at risk for significant weight loss and ordered a regular chopped diet with thin liquids, with all foods to be served in bite-sized pieces and requiring setup/cleanup assistance and indirect supervision during meals. Her tray card indicated a soft and bite-sized regular diet with no recorded dislikes. During a lunch observation, the posted whiteboard menu listed chili with beans, baby baked potato, cornbread/dinner roll, and grapes. The resident was served chili, a whole bread roll, and whole grapes; after refusing chili, she was given chicken noodle soup but did not receive any potatoes. She ate the whole roll and whole grapes quickly and independently without staff interaction. In a subsequent interview, the Dietary Manager, DON, and Administrator agreed that the roll should have been cut into bite-sized pieces, the resident should have received bananas instead of grapes, and potatoes should have been served, and confirmed that the facility was expected to provide a diet meeting the resident’s needs and that dislikes or allergies should be documented on the tray card.
Improper Handling of Food Containers and Lids During Meal Service
Penalty
Summary
The deficiency involves failure of dietary staff to prevent contamination of food containers and lids during meal preparation and service for all 78 residents. During a midday observation, a cook was seen taking temperatures of chili with beans, mashed potatoes, and pureed mixed vegetables and, while doing so, repeatedly touched the inside of each food container with her bare hand. In a separate observation, a dietary aide was seen touching the inside of the lids with bare hands while placing the lids on bowls of chili with beans and then placing these bowls on resident trays. When interviewed, the cook acknowledged she was not supposed to touch the inside of food containers with her hand when taking food temperatures, and the dietary aide stated she did not know whether she was supposed to touch the inside of the lids. The dietary manager later confirmed that kitchen staff were not supposed to touch the inside of food containers or lids with bare hands when taking food temperatures or placing lids on bowls of chili. The report states this failure had the potential to increase the risk of foodborne illness for all 78 residents in the facility.
Failure to Consistently Monitor and Document Nutritional Status and Weights
Penalty
Summary
The deficiency involves the facility’s failure to consistently and comprehensively manage nutritional services for a resident identified as being at risk for significant weight loss. The resident was admitted with dementia, chronic and acute kidney disease, and cellulitis of the left lower limb, and had a BIMS score indicating severe cognitive impairment. The admission MDS showed no significant weight loss prior to admission. Physician’s orders directed that the resident receive a regular chopped diet with thin liquids, be weighed weekly on shower days, be offered a bedtime snack each evening, and receive ProStat 30 mL twice daily to support wound healing. The care plan, revised shortly after admission, identified the resident as at risk for significant weight loss and directed that all foods be served as a regular diet cut into bite-sized pieces, that intake be monitored, and that the resident receive diet as ordered. The diet/tray card used by staff showed a soft and bite-sized regular diet and no recorded food or fluid dislikes. Review of the weight record showed weights of 118 lbs, 113.8 lbs, 114.0 lbs, and 110.0 lbs over several days, with no recorded weights after the last entry despite orders for weekly weights. The vitals report showed that meal intake was not documented for 10 of 46 meals since admission, contrary to the care plan and the facility’s Monitoring Nutrient Intake Policy, which required nursing to document percentage of each meal consumed and substitutions. The initial nutritional assessment documented that the resident was underweight and at risk for significant weight loss, with a plan to monitor for need of additional high-calorie supplements based on intake, skin, and weight trends, and for the RD to update the plan of care as needed. There was no documentation of facility follow-up related to the resident’s weight loss since admission, no evidence of efforts to ensure accurate meal intake documentation, and no evidence that weights were obtained as ordered. The DON and Administrator confirmed that no weights were documented after the last recorded date and that meal intake had not been consistently documented, despite the facility’s policies requiring monthly weights or more frequent monitoring as ordered, and recording of all obtained weights in the EMR.
Failure to Remove Staff Following Abuse Allegation
Penalty
Summary
The facility failed to implement protective measures following an allegation of abuse involving a certified nursing assistant (CNA) and a resident. According to the facility's Abuse Prevention Program policy, staff members accused of abuse are to be immediately removed from resident care duties and suspended pending the outcome of an investigation. However, after an incident in which a CNA was alleged to have acted aggressively, spoken in a condescending manner, and physically grabbed a resident's wrist despite the resident's objections, the CNA was allowed to continue working both during the remainder of the shift and on subsequent days while the investigation was ongoing. The resident involved was alert, oriented, and had a history of conditions including gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. The resident reported feeling that the CNA was abusive, describing the CNA as haughty, condescending, and physically forceful, including grabbing her wrist tightly and yelling in her face. Witnesses, including another CNA and an LPN, corroborated the resident's account, noting the CNA's aggressive behavior, refusal to leave when asked, and the resident's visible distress, including trembling and watering eyes. The LPN observed redness on the resident's wrist and reported the incident to the Director of Nursing promptly. Despite these observations and the facility's policy, the CNA continued to work with residents, including on other shifts and in areas where she could have contact with additional residents. The failure to remove the CNA from resident care duties during the investigation represented a lack of immediate protective action as required by the facility's own procedures, potentially affecting the safety and well-being of other residents.
Resident Subjected to Abusive Behavior by CNA During Care
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and able to communicate her needs, was subjected to abusive behavior by a Certified Nursing Assistant (CNA). The resident reported that the CNA spoke to her in a haughty, condescending, and dictatorial manner, insisted she move her own belongings, and threatened to leave if she did not comply. During care, the CNA grabbed the resident's wrist twice, did not release her grip when asked, and yelled in the resident's face from a close distance. The resident expressed feeling a little afraid during the incident and described the CNA's behavior as escalating. Although no marks were left, the resident stated the grip was tight and confirmed she felt the CNA was abusive. Other staff present corroborated the resident's account. Another CNA described the situation as a "power trip" and confirmed the CNA's condescending tone and refusal to let go of the resident's wrist. A Licensed Practical Nurse (LPN) who entered the room observed the resident visibly trembling and with watery eyes, and noted the CNA was speaking aggressively and inappropriately close to the resident's face. The LPN also observed slight redness near the resident's wrist and reported that the resident calmed after the CNA left. The incident was reported to the Director of Nursing, and statements were gathered for investigation.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframe. According to the facility's Abuse Prevention Program policy, allegations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made, and all other allegations must be reported within 24 hours. In this incident, a resident with intact cognitive function reported that a CNA spoke to her in a condescending and aggressive manner, grabbed her wrist tightly despite her requests to let go, and refused to leave the room when asked multiple times. The resident described the interaction as abusive and stated she felt afraid during the incident. Multiple staff members, including another CNA and an LPN, witnessed the event and corroborated the resident's account. The LPN observed the resident visibly upset, with watery eyes and trembling, and noted slight redness on the resident's wrist. The LPN also reported that the CNA continued to work the remainder of the shift after the incident. The LPN promptly reported the incident to the Director of Nursing and began gathering witness statements for an investigation. Despite the prompt internal reporting, the facility did not report the incident to the State Survey Agency within the required 24-hour period. The self-report to the state was made three days after the incident occurred, which is not in compliance with the facility's policy or federal regulations. This delay in external reporting constitutes the deficiency identified by the surveyors.
Failure to Report and Document Resident Transfer Accident
Penalty
Summary
A deficiency occurred when a resident with right-sided hemiplegia, impaired mobility, hypertensive intracerebral hemorrhage, chronic pain, and osteoarthritis was being transferred to the bathroom using an EZ stand. During the transfer, the resident's right arm was bumped against the door frame by CNA staff. The incident was not reported to the charge nurse or documented in the medical record as required by the facility's Resident Incident/Accident Reporting Protocol, which mandates immediate reporting and documentation of all incidents and accidents, regardless of severity. The resident later reported severe pain in the right arm to a registered nurse during a medication pass, prompting the facility to gather witness statements from the involved CNAs. Both CNAs confirmed the incident, noting that the resident's arm was hit during the transfer and that the resident declined an ice pack. The Director of Nursing confirmed that the incident was not reported to the nurse on duty, the charge nurse, or the oncoming shift, in violation of facility policy.
Failure to Monitor and Maintain Adequate Hydration for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received adequate fluid intake to maintain acceptable hydration. The resident, who had multiple diagnoses including multiple sclerosis, chronic kidney disease, weakness, and dysphagia, was consistently not meeting the recommended daily fluid intake of greater than 1,400 ml. Despite the facility collecting intake data, staff did not total or assess daily fluid intake, and there was no ongoing assessment for signs and symptoms of dehydration. The resident experienced significant weight loss and was hospitalized twice within a short period for conditions related to dehydration and aspiration pneumonia, both times requiring intravenous fluids. The facility's own policies required assessment and care planning for dehydration risk, including monitoring fluid intake, weighing residents weekly, and updating care plans as needed. However, the facility failed to weigh the resident upon readmission after hospitalization, did not weigh the resident weekly as ordered, and did not update or revise care plan interventions to address the ongoing risk of dehydration and weight loss. There was also a failure to timely communicate significant weight changes to the provider. Interviews with staff revealed confusion about who was responsible for totaling daily fluid intakes, and it was confirmed that no one was consistently performing this task. Documentation showed that the resident's fluid intake was regularly below the recommended amount, and there was no evidence of dehydration assessments being performed. The resident's care plan included approaches to encourage fluid intake and monitor for signs of fluid imbalance, but these interventions were not effectively implemented or updated in response to the resident's declining condition. The lack of daily monitoring and assessment contributed to the resident's repeated hospitalizations and significant weight loss.
Delay in Providing Timely Toileting Assistance
Penalty
Summary
A deficiency occurred when a resident who required extensive assistance for toileting was not provided timely care after requesting to use the bathroom. The resident, who had a history of orthopedic aftercare following surgical amputation, was non-weight bearing on the right leg, and required the use of a Hoyer lift with assistance from two staff members, asked a CNA for help to use the bathroom. The CNA informed the resident that she was on a two-hour toileting schedule and would need to wait, despite the resident not being on such a schedule according to her care plan. The resident waited approximately 1 hour and 20 minutes before being assisted to the bathroom. During this period, staff communication and follow-through were lacking. The CNA who received the request prioritized other residents and did not seek immediate assistance from other staff, even though the Director of Nursing later clarified that staff are expected to respond to such requests as soon as possible. Another CNA, who was supposed to assist, was on break and did not check in with the resident upon returning. The resident was observed participating in an activity during this time, and no staff approached her to ask if she needed to use the bathroom, despite her earlier request. The facility's policy emphasizes person-centered care and the importance of honoring resident preferences and needs, including timely assistance with toileting. The resident expressed discomfort and concern about potentially having an accident due to the delay. Interviews with staff revealed confusion about the resident's toileting schedule and a lack of clear communication regarding her care plan, which contributed to the delay in providing necessary assistance for activities of daily living.
Failure to Notify Physician of Resident's Critical Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when the resident experienced a significant change in condition. The resident, who had a history of coronary artery disease, diabetes mellitus type 2, chronic heart failure, and other conditions, was admitted to the facility after hospitalization for acute hyperkalemia. On the day of admission, the resident's oxygen saturation fell to 71%, and their pulse dropped below 50, which required immediate notification to the physician according to the facility's policy and the INTERACT change of condition reporting tool. Despite the critical changes in the resident's condition, there was no documentation indicating that the physician was notified. The facility's policy required immediate notification of the physician in such cases, but the staff failed to follow this protocol. The resident's condition was initially addressed by administering oxygen, which temporarily improved their oxygen saturation levels. However, the lack of communication with the physician meant that the resident's overall care and potential treatment adjustments were not adequately managed. Interviews with various staff members, including the MDS nurse, LPNs, and the Regional Clinical Director, revealed inconsistencies in the communication process. The Director of Nursing claimed to have notified the physician via email, but this was not documented in the resident's medical record, and the physician did not respond until two days later. The facility's failure to document and properly communicate the resident's change of condition to the physician resulted in a deficiency in the standard of care provided to the resident.
Inadequate Supervision and Hot Food Management Leads to Resident Burns
Penalty
Summary
The facility failed to provide adequate supervision and assistance during meals, leading to a resident suffering second-degree burns from hot soup. The incident occurred when the resident, who required supervision during meals, was left unsupervised in the dining room. The soup temperature was recorded at 177 degrees Fahrenheit, significantly higher than the facility's policy of serving hot liquids at a maximum of 135 degrees Fahrenheit. This lack of supervision and failure to adhere to temperature guidelines resulted in immediate jeopardy. The resident involved had a history of cerebral infarction, aphasia, weakness, dysphagia, diabetes mellitus type 2, and hemiplegia affecting the right side. The resident's care plan indicated a need for supervision and assistance during meals, including the use of a clothing protector and lidded cups to prevent spills. Despite these documented needs, the resident was not provided with the necessary supervision or protective measures during the meal when the incident occurred. Interviews with staff revealed inconsistencies in the understanding and implementation of supervision requirements. Staff members were unclear about who was responsible for supervising residents in the dining room, and there was a lack of adherence to the facility's policy on serving temperatures. The dietary manager and staff were not adequately educated on the correct serving temperatures, and there was no consistent monitoring of food temperatures at the point of service, contributing to the incident.
Removal Plan
- All residents have been assessed and care plans have been updated to the level of supervision during meals.
- Temperatures have been taken in the kitchen every 15 minutes on the serving steam table tray line due to a need for a part replacement.
- Test trays are done at the point of service for all residents in the dining room and one on each hall tray carts to be checked prior to beginning of service to verify food temp is 135-150 degrees.
- Residents that have a risk of hot liquid injury have cups with lids that snap on and are more difficult to remove and also have staff supervision per their care plan approach as agreed upon by IDT and therapy.
- Dietary staff have had direct supervision at meals and assist taking temperatures of foods prior to service.
- Dietary staff is being educated on the correct temperatures of service of food to be between 135-150 degrees at the point of service to the residents.
- Policies have been changed to reflect this change.
- Nursing staff is being educated on the definition of supervision that is expected in the dining room with the residents that require supervision. This is being audited at every meal to monitor compliance with every meal that residents at risk are having the correct level of supervision that is required to maintain safety with hot liquids/foods.
- Maintenance checked the steam table and parts were ordered and expedited. Replaced prior to the start of service.
- Facility will continue with weekly checks of the steam table for proper function. Due to faulty parts the temps on the food in the steam table were checked every 15 minutes to maintain safe temps.
- QAPI meeting held related to PIP started in relation to the changes that need to be completed.
- Staff education started with temperature changes in the dietary dept.
- Education to nursing staff related to the definition of supervision: 1:1, direct, and direct.
- Care plans related to the level of supervision that is required for residents at risk with hot liquids updated and educated to nursing staff.
- All education is ongoing with this being completed prior to the start of the next working shift.
- Both tray audits and the supervision audits are being completed at all 3 meals 7 days per week to maintain the safe environment for the residents at meal time.
- Resident council meeting held for the update of the residents to the recent changes and the updates to dining service.
- At this time all staff that have worked in the facility have been educated to the changes in policy and the level of supervision that is to be provided in the dining room at all meals.
Inadequate Investigation of Resident Altercation
Penalty
Summary
The facility failed to ensure a thorough investigation of an incident involving potential abuse between two residents. Resident 6, who has severe cognitive impairment and a history of dementia with mood disturbances, was involved in an altercation where they hit Resident 5 on the chest. The incident was witnessed by staff, and immediate actions were taken to separate the residents and provide supervision for Resident 6. However, the facility did not conduct interviews with other residents to determine if there were additional instances of abuse, as required by their Abuse Prevention Program Policy. The facility's policy mandates that all involved persons, including potential witnesses, should be interviewed during an investigation of resident-to-resident altercations. Despite this, the Nursing Home Administrator and Assistant Director of Nursing decided not to interview other residents, considering the incident isolated to Residents 5 and 6. This decision was made after consultation with the facility's regional director, which led to a deficiency in the investigation process as it did not fully comply with the facility's established procedures for handling potential abuse cases.
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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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