New Glarus Home
Inspection history, citations, penalties and survey trends for this long-term care facility in New Glarus, Wisconsin.
- Location
- 600 2nd Ave, New Glarus, Wisconsin 53574
- CMS Provider Number
- 525630
- Inspections on file
- 24
- Latest survey
- February 16, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at New Glarus Home during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a documented history of sexually inappropriate behavior toward other male residents had his supervision progressively reduced and ultimately discontinued despite prior incidents of non-consensual genital touching. Later, this resident was found in another cognitively intact resident’s room with his hand inside the other resident’s pants, touching his penis and upper thigh; the second resident reported the contact was not consensual. Staff interviews and records confirmed that the abusive resident was known to be sexually inappropriate, and that facility policies required prevention of abuse and monitoring of residents with behaviors that might lead to conflict, but supervision was not consistently maintained, leading to an Immediate Jeopardy finding related to failure to protect residents from sexual abuse.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident due to the facility's failure to implement and communicate care plan interventions, such as 1:1 supervision and motion sensor alarms. Staff were unaware of the required interventions, and documentation and education regarding the incident were incomplete, resulting in inadequate protection for the resident.
Two CNAs did not receive required annual performance evaluations, as confirmed by record review and interview with the DON, who stated that yearly evaluations are expected for all CNAs.
A registered nurse did not perform required hand hygiene after removing gloves at multiple points during wound care for a resident with a left knee wound. Despite facility policies mandating handwashing after glove removal, the nurse continued the procedure without proper hand hygiene, a lapse confirmed by both the nurse and the DON during interviews.
The facility experienced a COVID-19 outbreak affecting 38 residents and 18 staff members due to inadequate infection control measures. Staff were observed improperly doffing PPE in hallways, contaminating clean PPE, and not adhering to hand hygiene protocols. The facility failed to document COVID-positive residents' symptoms and did not fit test agency staff for N95 masks. The infection preventionist was not adequately trained, and testing for symptomatic residents was delayed.
Two residents' rights to receive visitors of their choosing were violated when the facility restricted visits based on the wishes of their POAs, who only had authority over health care decisions. Despite one resident being cognitively intact and the other having moderate cognitive impairment, the facility acted on the POAs' requests without legal authority, leading to a deficiency in honoring residents' visitation rights.
A resident with severe cognitive impairment was found in another resident's room, engaging in inappropriate contact. The facility failed to implement new interventions or update care plans to prevent recurrence. The incident was not reported to the state agency within the required timeframe, and not all staff received abuse training.
A facility failed to report an alleged abuse incident within the required 2-hour timeframe. A CNA found a resident sitting on another resident's bed, with the latter's brief pulled down and being touched inappropriately. The incident was discovered at 4:30 AM, but the report to the State Agency was delayed until 10:39 AM. Both residents were non-interviewable, and the facility initially viewed the incident as a resident-to-resident altercation, contributing to the reporting delay.
A facility failed to investigate and prevent a resident-to-resident abuse incident where one resident was found fondling another. The facility did not update care plans or implement increased supervision, and no abuse education was provided to staff. Interviews with the DON and NHA revealed no specific interventions were put in place to ensure resident safety.
A resident at high risk for pressure injuries developed a Stage 3 pressure injury due to the facility's failure to implement preventive measures and timely interventions. Despite being aware of the resident's high risk status, the facility did not have skin interventions in place, and there were delays in notifying the physician and applying appropriate wound care. Observations revealed inconsistencies in dressing management, particularly during shifts with agency staff.
A resident experienced severe weight loss due to the facility's failure to monitor her nutritional status and implement appropriate interventions. Despite being at risk, the resident's care plan was not updated, and her weight was not consistently monitored. The registered dietician's recommendations were not followed up on, and the resident's cognitive decline was not addressed, leading to continued nutritional decline.
The facility's QAA Committee did not include the required members, specifically the DON and IP, during QAPI meetings in February and June 2024. The facility's QAPI plan failed to list the IP as a member, contrary to policy. The NHA confirmed the absence of these members, affecting the facility's compliance with regulatory requirements.
The facility failed to maintain an effective Infection Control Program, lacking a water management team and proper documentation. Clean linens were transported uncovered, and staff lacked appropriate PPE. A resident with infection symptoms was not added to the line list, indicating poor communication and documentation practices.
The facility did not consistently offer bedtime snacks to residents when there was a 15-hour gap between dinner and breakfast, affecting all residents. Staff confirmed that snacks were not routinely provided, and the facility's policy requiring bedtime snacks was not followed. Meals were also served late, contributing to the issue.
The facility failed to maintain a sanitary environment in its kitchen, affecting all residents. Staff were observed without hair restraints, wet dishes were improperly stacked, dented cans were in circulation, and opened food items were not labeled or dated. Additionally, kitchen equipment was found unclean, violating facility policies.
The facility did not have enough trained staff in the food service department, leading to delayed meal services for residents. Meals were consistently served late, with breakfast and lunch delayed by up to 55 minutes. Residents, including those with complex medical conditions, expressed concerns about the timeliness of their meals. The facility's meal schedule was not followed, and there was no system to track actual delivery times, contributing to the issue.
The facility failed to follow its policy regarding the Resident Council, resulting in delayed responses to grievances and unauthorized staff presence at meetings. Residents reported not receiving timely follow-ups on their concerns, and the previous administrator attended meetings uninvited. Issues such as delayed call light responses and inconsistent medication times were documented but not addressed promptly, contributing to resident dissatisfaction.
Two residents reported cold showers, with water temperatures confirmed to be below comfortable levels. The Maintenance Director was unaware of the process for checking water temperatures, and no records of temperature checks were found. The Nursing Home Administrator expected maintenance staff to be knowledgeable about appropriate water temperatures and the facility's policy, but this was not the case.
The facility failed to ensure a safe environment by improperly charging motorized wheelchair batteries outside of fire-safe areas and inadequately supervising a resident transfer without a gait belt. The DON was unaware of the charging practices, and an LPN confirmed the need for a gait belt during the resident's transfer, which was not used despite the resident's dizziness and fear.
Two residents with PTSD did not receive appropriate care due to incomplete care plans lacking details on triggers, interventions, and goals. Staff were unaware of the residents' PTSD needs, indicating a communication gap. The facility's policy on trauma-informed care was not followed, leading to unmet mental and psychosocial needs.
A facility's medication error rate exceeded the acceptable threshold of 5%, with two errors observed. An LPN crushed and administered Januvia against label instructions, resulting in a dosing error for a resident with Type 2 diabetes. Another resident did not receive their prescribed levothyroxine due to it not being available, despite it being in the contingency supply, leading to an omission error.
The facility failed to promptly resolve grievances for two residents. One resident requested her catheter flush be scheduled at 8:00 AM to attend activities and church on time, but it was consistently done after 9:00 AM. Another resident reported receiving bedtime medications late and was informed of the resolution four weeks later, violating the facility's policy for timely communication.
A facility failed to report an allegation of verbal abuse involving a resident who was told by staff to "keep his mouth shut" after a spill incident. Another resident overheard and reported the incident, but the facility did not notify the state agency as required by their abuse policy. The Director of Nursing and Social Worker acknowledged the oversight, and the Nursing Home Administrator was unaware of the incident until reviewed with a surveyor.
A facility failed to report and thoroughly investigate an allegation of verbal abuse involving a resident who was told by staff to keep his mouth shut after an incident. Another resident overheard and reported the event, but the facility did not notify the state agency or conduct a proper investigation, as confirmed by the DON and Social Worker.
A resident with multiple mental health diagnoses stayed in the facility beyond the 30-day exemption period without a required PASRR Level II screen. The oversight was due to departmental turnover and changes in the electronic charting system, as acknowledged by the facility's staff.
Two residents experienced significant incidents due to the facility's failure to adhere to care plans and provide adequate supervision. One resident, with severe cognitive impairment, was not transferred according to her care plan, resulting in a fall and a left distal femur fracture. Another resident, at risk for elopement, left the facility unnoticed due to a malfunctioning WanderGuard system. These incidents highlight deficiencies in the facility's safety and supervision protocols.
A resident with severe dementia was restrained and given medication via oral syringe against their apparent refusal, violating their right to refuse medication. The facility's staff did not adhere to the care plan or policies, which emphasize respecting residents' rights and managing agitation appropriately. Interviews with staff confirmed the bypassing of the resident's right to refuse medication.
The facility did not conduct a thorough investigation into an alleged abuse incident involving a resident. Despite reporting the allegation to the state agency, the facility failed to interview key witnesses and staff, including a potential witness identified by a CNA and the supervising nurse of the accused med tech. The Director of Nursing confirmed the absence of additional interviews and related audits or education, highlighting a deficiency in the facility's investigation process.
A resident with increased exit-seeking behaviors was not provided adequate supervision, leading to an elopement incident. Despite documented wandering and confusion, the facility failed to reassess the resident's elopement risk or update the care plan. The incident was not recorded in the resident's electronic health record, contrary to facility policy.
The facility did not ensure all drugs and biologicals were stored and labeled in accordance with professional principles, leading to the administration of expired medications. An expired Aspirin tablet was given to a resident, and additional expired and unlabeled medications were found in other medication carts. Interviews confirmed that the facility's policies were not consistently followed.
Failure to Prevent Resident-to-Resident Sexual Abuse by Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with a known history of inappropriate sexual behavior. One resident (R1), who had a documented history of touching other male residents inappropriately, was initially placed on 1:1 supervision after incidents on 4/27/25 and 4/28/25 in which he was found with his hands in other male residents’ briefs or crotch areas, touching their genitals. Over the following months, the facility progressively reduced R1’s supervision from 1:1 to 15‑minute checks, then to one‑hour checks, then to two‑hour checks, and ultimately discontinued his supervision entirely on 12/12/25, despite his history of sexually inappropriate conduct. R1’s medical record shows multiple medical conditions, including hemiplegia and hemiparesis following a stroke, diabetes mellitus, hypertension, and other cardiovascular conditions. His MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and noted physical and verbal behaviors directed toward others. His care plan identified a behavior problem of inappropriate sexual conduct with other residents and inappropriate comments to staff, and included interventions such as providing care in pairs and, later, specific directions to intervene, remove him from other residents’ rooms, and protect the rights and safety of others. Staff interviews confirmed that R1 was known to be sexually inappropriate, particularly with male residents, and that interventions such as 1:1 supervision when up in his wheelchair, 15‑minute checks when in bed or recliner, and a door alarm were in place at the time of the survey. On 1/18/26, after supervision had previously been discontinued and then later re‑implemented, R1 was found in another resident’s (R2’s) room inappropriately touching R2 in his private area under his clothing. R2, who had diagnoses including acute respiratory failure with hypoxia, COPD, sepsis, Alzheimer’s disease, and hypertension, was documented as cognitively intact on his MDS, able to understand and be understood, and having no behaviors. Witness accounts from staff indicated that R1’s hand was inside R2’s pants, touching R2’s penis and upper thigh, and R2 stated that the touching was not consensual. The facility’s abuse, neglect, and exploitation policy required prevention of abuse, identification and monitoring of residents with behaviors that might lead to conflict, and increased supervision to protect residents from harm, but the facility’s reduction and discontinuation of R1’s supervision, despite his known history of sexually inappropriate behavior, led to the incident of non‑consensual sexual contact. Surveyors determined that this failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm and resulted in a finding of Immediate Jeopardy beginning on 1/18/26.
Removal Plan
- Residents were separated and the incident was reported to the NHA.
- Staff provided statements; additional staff interviews were completed as needed.
- Law enforcement responded and interviewed the residents.
- Residents had mood, behavior, and appetite monitored.
- Residents received skin assessments.
- Residents’ physicians were updated; the POA was updated; the resident who is their own decision maker declined notification.
- All residents on the wing with a BIMS less than 7 received skin checks.
- All residents with a BIMS greater than 7 were interviewed.
- The resident was placed on 1:1 supervision when up in a wheelchair.
- The resident was placed on 15-minute checks when in bed or recliner.
- Alarms were implemented on the resident’s door and at ground level to alert staff.
- Residents’ psychosocial well-being care plans were updated.
- Resident relationship, intimacy, and sexuality histories were completed; both residents denied wanting a relationship.
- Staff education was initiated regarding abuse with emphasis on sexual abuse, 1:1 definition and expectations, resident-specific interventions, and 15-minute checks; charge nurse and leadership ensured staff were educated prior to the start of their shifts.
- The social worker interviewed the residents and both stated they feel safe.
- The DON and VP of Nursing interviewed the resident and the resident stated they feel safe.
- BCS services were offered to the residents and both declined.
- The resident was offered materials to help with hypersexuality and declined.
- A care plan meeting was held with the resident, the facility, and the POA to discuss behaviors, the plan moving forward, and activities of interest.
- The Medical Director was updated regarding the incident between the residents.
Failure to Implement and Communicate Abuse Prevention Interventions
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of dementia was subjected to inappropriate sexual contact by another resident, who also had severe cognitive impairment and behavioral disturbances. The incident occurred in a common area and was witnessed by a registered nurse, who intervened and separated the residents. The nurse reported the incident to the nurse manager later in the day after being advised by another nurse that it needed to be reported. The initial response included documenting the incident and notifying management. Following the incident, the care plan for the resident who committed the inappropriate act was updated to include 1:1 supervision and the installation of a motion sensor alarm on the resident's doorway and bathroom. However, during subsequent observations, these interventions were not consistently implemented. Staff were observed leaving the resident unsupervised in common areas, and the motion sensor alarm did not always function as intended. Additionally, the care plan interventions were not reflected in the CNA Kardex, and staff were not consistently aware of the required supervision or interventions. Interviews with multiple staff members revealed a lack of awareness and education regarding the updated care plan interventions. Some staff had not received any education since returning from leave, and there was confusion about how care plan changes were communicated and implemented. The facility's documentation showed that only a fraction of the staff had signed off on education related to the incident, indicating a gap in staff training and communication. These failures resulted in the resident not being adequately protected from further abuse, as required by regulations.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two of five Certified Nursing Assistants (CNAs) reviewed. Specifically, one CNA hired on 5/3/23 and another hired on 2/10/23 did not have documented annual performance evaluations for 2024. This deficiency was identified through interview and record review, with the Director of Nursing confirming that yearly evaluations are expected for all CNAs.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene during wound care for a resident. During an observed wound care procedure, a registered nurse performed hand hygiene initially and donned gloves and a gown before removing the resident's old bandage. However, after removing gloves at multiple points during the procedure, the nurse did not perform hand hygiene before donning new gloves, contrary to facility policy and physician orders. The nurse continued the wound care process, including cleansing and dressing the wound, without appropriate hand hygiene between glove changes. Interviews with the nurse and the Director of Nursing confirmed that hand hygiene should have been performed after each glove removal, and both acknowledged that this was not done during the observed procedure. The facility's policies on clean dressing changes and hand hygiene specifically require handwashing after glove removal to prevent infection and cross-contamination, but these protocols were not followed during the care of the resident with a left knee wound.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility is experiencing a significant COVID-19 outbreak affecting all six units, with 38 residents and 18 staff members testing positive. The outbreak began when three residents and one staff member tested positive, and the facility failed to implement effective infection control measures. Staff were observed improperly doffing PPE in the hallway, contaminating clean PPE with dirty PPE, and not adhering to proper hand hygiene protocols. Additionally, the facility did not document COVID-positive residents' signs and symptoms on the line list or elsewhere, and agency staff were not fit tested for N95 masks. The facility's infection preventionist, who recently assumed the role, was not provided with adequate training before starting. The infection preventionist admitted to not documenting symptoms on the line list and not conducting group education on PPE usage. The Director of Nursing acknowledged that the facility should have tested residents R16 and R19 when they first showed symptoms, but testing was delayed by a day. The facility also failed to fit test agency staff for N95 masks, which is a critical component of the infection control program. Observations by the surveyor revealed that staff members were not following proper PPE protocols. Staff were seen exiting a COVID-positive room with PPE on, removing it in the hallway, and placing used PPE on the isolation cart, which led to contamination. The staff also failed to perform hand hygiene before applying new masks. These actions demonstrate a breach in infection control practices, contributing to the spread of COVID-19 within the facility.
Violation of Residents' Visitation Rights
Penalty
Summary
The facility failed to honor the residents' rights to receive visitors of their choosing at the time of their choosing for two residents, R1 and R4. R1's medical record and a sign at the nurses' station indicated that R1's son, daughter, and daughter-in-law were not allowed to visit, based on the wishes of R1's Power of Attorney (POA), despite R1 being cognitively intact and expressing a desire to visit with them. The facility's actions were based on the POA's instructions, which were not legally supported as the POA only had authority over health care decisions, not visitation rights. Similarly, R4's medical record and a sign at the nurses' station indicated that a family member, FM E, was not allowed to visit, based on the request of R4's POA. R4 had moderate cognitive impairment, and the facility acted on the POA's request without legal authority, as the POA's power was limited to health care decisions. Staff were instructed to ask FM E to leave if they attempted to visit, and if they refused, to contact the administrator. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed a lack of understanding regarding the limitations of a POA's authority over visitation rights. The staff believed that the POA could restrict visitors, which contradicted the residents' rights to have visitors of their choosing. The facility's actions were not aligned with the residents' rights as outlined in their own handouts and policies, which emphasized the residents' rights to private and unrestricted visits.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that residents were free from sexual abuse, as evidenced by an incident involving two residents, R2 and R3. R3, who has severe cognitive impairment due to vascular dementia, was found in R2's room, sitting on the edge of R2's bed with R2's Depends unfastened, and fondling R2 between the butt cheeks. R2, who also has severe cognitive impairment, remained asleep during the incident and showed no signs of pain or emotional disturbance. The incident was reported to the Nursing Home Administrator, and an investigation was initiated. The facility's policy on abuse, neglect, and exploitation requires the development and implementation of written policies and procedures to prevent such incidents. However, the facility did not put any new interventions in place after the incident to prevent it from happening again. R3 was placed on 15-minute checks, but there was no documentation in R3's medical record to confirm this. Additionally, the care plans for both R2 and R3 were not updated following the incident, and no specific measures were taken to ensure the safety of other residents. The Director of Nursing and the Nursing Home Administrator acknowledged that the incident was not reported to the state agency within the required two-hour timeframe. Furthermore, not all staff received abuse training following the incident, with only 117 out of 175 staff members having completed the training. The facility's failure to implement adequate protective measures and update care plans after the incident highlights a deficiency in ensuring resident safety and compliance with abuse prevention policies.
Delayed Reporting of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe as per their policy. The incident involved two residents, where one resident was found by a CNA sitting on the edge of another resident's bed, with the latter's brief pulled down and being touched inappropriately. The incident was discovered at approximately 4:30 AM, but the report to the State Agency was not made until 10:39 AM, exceeding the 2-hour reporting requirement for abuse allegations. The facility's policy mandates that such incidents be reported immediately, but no later than 2 hours after the allegation is made. The residents involved were both non-interviewable, with low BIMS scores indicating cognitive impairment. The resident who was touched did not exhibit signs of pain or emotional disturbance and remained asleep during the incident. The facility's interim administrator was informed of the incident at 9:00 AM, and the Director of Nursing was notified at 6:17 AM. Despite these notifications, the report to the State Agency was delayed, and the facility initially considered the incident as a resident-to-resident altercation rather than abuse, which contributed to the reporting delay.
Failure to Investigate and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an accusation of physical abuse involving two residents. One resident was found in another resident's room, sitting on the edge of the bed with the other resident's brief unfastened, and was observed fondling the resident. The facility did not implement measures to prevent a recurrence of this incident, nor did it provide abuse education to all staff members. The facility's policy on abuse, neglect, and exploitation requires the development and implementation of written policies and procedures to prohibit and prevent abuse, including the establishment of a safe environment and the identification and monitoring of residents with behaviors that might lead to conflict. However, after the incident, the facility did not update the care plans for the involved residents, nor did it document any increased supervision or monitoring of the resident who was the alleged perpetrator. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that no specific interventions were put in place to ensure the safety of the residents involved or other residents in the facility. The DON acknowledged that no new interventions were implemented following the incident, and the NHA considered the incident isolated, not warranting facility-wide staff education. The lack of documentation and follow-up actions highlights the facility's failure to adhere to its own policies and procedures regarding abuse prevention and response.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and manage pressure injuries for a resident identified as R2. R2, who was at high risk for pressure injuries due to conditions such as cerebral palsy and schizophrenia, developed a Stage 3 pressure injury on the right ischium. The facility did not implement appropriate interventions for pressure injury prevention despite being aware of R2's high risk status as indicated by a Braden Scale score of 12, which signifies a high risk for skin breakdown. The facility's policy on pressure injury prevention and management was not followed, as no skin interventions were in place prior to the development of the Stage 3 pressure injury. The deficiency was further compounded by the lack of timely and appropriate response once the pressure injury was discovered. The facility's records show that the pressure injury was not identified until it had progressed to Stage 3, and there was a delay in notifying the physician and implementing a treatment plan. The facility's Director of Nursing (DON) confirmed that no skin interventions were in place before the injury was discovered and acknowledged that this was not acceptable. Additionally, there was no evidence of a root cause analysis being conducted to understand how the pressure injury developed to such an advanced stage. Observations and interviews with staff revealed inconsistencies in wound care management, including instances where R2's dressing was not in place, particularly during the night shift when agency staff were more frequently on duty. The dressing was often found to be off or soiled, and there was a lack of communication and follow-up to ensure the dressing was reapplied promptly. The DON admitted that there was no education provided to staff following the discovery of the pressure injury, and there was an indication that some staff were not diligent in changing R2's dressing, which further contributed to the deficiency.
Failure to Monitor and Address Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R11, maintained acceptable nutritional and hydration status, resulting in severe weight loss. R11 experienced a weight loss of 20.6 pounds, or 12.86%, over a period of two months and ten days. Despite being added to the facility's Critical At Risk monitoring, R11's care plan was not updated to address her nutritional status or risk, and she continued to be listed as overweight. The facility's policy required monthly weight checks, but R11 was not weighed in November, and there was no documentation of refusals to be weighed. R11's meal intake records showed inconsistent consumption, with 38% of recorded meals indicating less than 50% intake. Despite this, no new dietary interventions were implemented in November or December. The registered dietician (RD) was aware of R11's poor intake and significant weight loss but did not document any follow-up on a recommendation for mirtazapine, an appetite stimulant. Additionally, the RD was not informed of R11's cognitive decline, which could have warranted further assessment and intervention. The facility's failure to monitor R11's weight and meal intake consistently, along with the lack of appropriate interventions, contributed to her severe weight loss. The registered dietician's recommendations were not documented as being followed up on, and there was no evidence of reassessment of R11's ability to feed herself following a decline in her cognitive status. This lack of action and communication among staff members led to R11's continued weight loss and nutritional decline.
QAA Committee Lacks Required Members and Quarterly Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required members and did not meet the quarterly attendance requirements. Specifically, the QAPI meetings for February and June 2024 did not include the Director of Nursing (DON) or the Infection Preventionist (IP), which are mandatory members according to the facility's policy. The facility's QAPI plan did not list the IP as a member, which is a deviation from the policy that requires the IP's presence. This oversight has the potential to affect all 90 residents residing within the facility. During the survey, it was noted that the QAPI sign-in sheets for the first and second quarters of 2024 lacked signatures from the DON and IP, while the third and fourth quarters had all required members present. The Nursing Home Administrator (NHA) confirmed the accuracy of the attendance records and acknowledged the absence of the DON and IP in the meetings. The NHA also failed to mention the IP as a regular attendee when asked about the committee's composition, indicating a lack of adherence to the established QAPI policy.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to establish and maintain an effective Infection Control Program, which included a water management program to prevent the spread of Legionella. Despite having policies in place, the facility did not have an active water management team, and the necessary documentation, such as the water management program binder, was missing. The Maintenance Director admitted that the binder was discarded by a previous employee, and there were no routine meetings to discuss water management and infection control risks. Although Legionella tests were conducted, the lack of a comprehensive program and team meetings indicates a significant oversight in infection prevention. Additionally, the facility did not adhere to proper laundry handling procedures, as observed by the surveyor. Clean linens were transported uncovered through common areas and stored inappropriately close to soiled laundry. The housekeeping staff did not have access to appropriate personal protective equipment, such as gowns or aprons, when handling dirty laundry. The Infection Preventionist acknowledged that clean laundry should be covered and that gowns should be available for staff, highlighting a failure to follow established infection control policies. Furthermore, a resident who exhibited signs of infection, including a low-grade fever and emesis, was not added to the facility's infection control line list. The Infection Preventionist was not informed of the resident's symptoms, which is a breach of the facility's policy to monitor and document potential infections. This oversight in communication and documentation further demonstrates the facility's inadequate infection control practices.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that snacks were consistently offered to residents at bedtime when there were more than 14 hours between the evening meal and breakfast. This deficiency was observed to potentially affect all 90 residents across all six units. Residents voiced concerns about not being offered snacks at bedtime, and staff from various halls confirmed that snacks were not consistently provided. The facility's policy required that all residents be offered a bedtime snack unless specified otherwise in their care plan, but this was not being adhered to. Observations and interviews revealed that meals were often served late, with breakfast being served 55 minutes past the scheduled time on one occasion. Staff members, including CNAs and an RN, indicated that snacks were not routinely offered at bedtime, and the facility no longer used a snack cart. The Dietary Manager and Regional Food Service Director acknowledged the 15-hour gap between supper and breakfast and confirmed that nursing staff were expected to offer snacks, but this was not happening consistently. The Nursing Home Administrator also reviewed the facility's snack policy and acknowledged the deficiency.
Sanitation and Food Safety Deficiencies in Facility's Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in its food preparation, storage, and distribution areas, potentially affecting all 90 residents. Multiple staff members, including the Dietary Manager, Certified Nursing Assistant, Dietary Supervisor, and Regional Dietary Director, were observed in the food preparation area without wearing required hair restraints, violating the facility's Uniform Dress Code policy. Additionally, the Dining Room Attendant was seen stacking wet dishes, which led to a white film buildup and condensation inside the cups and mugs, contrary to the facility's policy on air drying dishes. The surveyor also noted several issues with food storage and equipment cleanliness. Dented cans were found in circulation, and opened food items were not labeled or dated as required by the facility's Food and Supply Storage policy. Furthermore, stored kitchen equipment, such as mixers and a microwave, were found with food particles, indicating they had not been cleaned properly before storage. These observations were confirmed by the Dietary Manager and Regional Dietary Director, who acknowledged the lapses in following the facility's policies.
Insufficient Staffing in Food Service Leads to Delayed Meals
Penalty
Summary
The facility failed to ensure a sufficient number of trained staff in the food service department, resulting in delayed meal services for several residents. Observations and interviews revealed that meals were consistently served late, with breakfast and lunch being delayed by up to 55 minutes past the scheduled times. Residents expressed concerns about the timeliness of their meals, and one resident documented the delays over several weeks, showing a pattern of late meal service. The facility's meal schedule was not adhered to, and the dietary staff did not record the actual times meals were delivered to the wings. The deficiency affected multiple residents, including those with complex medical conditions such as hyperlipidemia, heart disease, and vascular dementia. Despite the facility's meal schedule outlining specific times for meal service, the dietary staff failed to deliver meals on time, and there was a lack of coordination in the food service process. Interviews with the Dietary Manager and Regional Director confirmed that the staff should follow the scheduled times, but there was no system in place to track the actual delivery times, contributing to the ongoing issue of late meal service.
Failure to Adhere to Resident Council Policy and Meeting Autonomy
Penalty
Summary
The facility failed to adhere to its policy regarding the Resident Council, which resulted in deficiencies related to the handling of grievances and the autonomy of resident meetings. The policy mandates that the management team must respond to concerns, complaints, or recommendations within 10 business days. However, residents reported that they only received follow-ups at the subsequent monthly Resident Council meetings, which is a delay from the stipulated timeframe. This lack of timely communication was confirmed by the Social Worker and the Nursing Home Administrator, who acknowledged the facility's failure to comply with its policy. Additionally, the facility did not respect the residents' right to hold meetings without staff presence, as required by the facility's policy. Residents expressed that the previous administrator attended meetings uninvited, which was against their wishes. This intrusion into the Resident Council meetings was corroborated by both the Social Worker and the Nursing Home Administrator, who confirmed that residents should be allowed to meet independently. The Resident Council minutes and grievance forms highlighted several unresolved issues, such as delayed responses to call lights, inconsistent medication administration times, and inadequate staffing levels. These concerns were documented but not addressed within the required timeframe, further illustrating the facility's failure to act promptly on resident grievances. The facility's inaction and disregard for the established policy contributed to the residents' dissatisfaction and the deficiency noted by the surveyors.
Facility Fails to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, as evidenced by the cold water temperatures in the shower rooms. Resident R391, who has a moderately intact cognitive status, reported that the showers have been cold since admission. During an interview, the surveyor confirmed the water temperature in the shower room was 67.7°F, which decreased to 64.4°F after running for six minutes, remaining cold to the touch. A sign in the shower room suggested turning on additional water sources to warm the shower water, but this did not increase the temperature. Resident R42, who is cognitively intact, also reported that the showers were usually cold and uncomfortable. The Maintenance Director, who has been at the facility for eight months, was unaware of the process for checking water temperatures and confirmed there were no records of such checks. The Nursing Home Administrator expected maintenance staff to know the appropriate water temperatures and the facility's policy on safe water temperatures, but this was not the case. The facility's failure to ensure appropriate water temperatures compromised the residents' comfort and safety.
Failure to Ensure Safe Charging of Motorized Wheelchairs and Proper Resident Transfer
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents using motorized wheelchairs. The surveyor observed a motorized wheelchair battery being charged in the 600 hall dining room, not behind a fire-safe door, which is against safety protocols. The Director of Nursing (DON) acknowledged that batteries should be charged behind a fire-safe door to prevent fire hazards due to shock or spark. However, the DON was unaware that staff were charging the electric wheelchair in the activity area and had not addressed the issue at the time of the survey. Additionally, the facility did not provide adequate supervision during the transfer of a resident who was feeling ill and dizzy. The resident, who was severely cognitively impaired and required supervision or assistance during transfers, was assisted by two CNAs without the use of a gait belt, despite the resident expressing feelings of dizziness and fear. The Licensed Practical Nurse (LPN) who witnessed the transfer confirmed that a gait belt should have been used, and the resident's care plan indicated the need for caregiver assistance with a four-wheeled walker.
Deficiency in PTSD Care Planning for Residents
Penalty
Summary
The facility failed to ensure that residents diagnosed with mental disorders or psychosocial adjustment difficulties, specifically PTSD, received appropriate treatment and services. Two residents, R41 and R65, were identified as not having comprehensive care plans that addressed their PTSD diagnoses. R41's care plan lacked details on known triggers, personalized interventions, and goals related to her past trauma, despite her history of PTSD linked to a prior medical procedure. The care plan only addressed her mood problems related to major depressive disorder without specific interventions for PTSD. R65, diagnosed with PTSD, schizotypal disorder, obsessive-compulsive disorder, and major depressive disorder, also did not have a personalized care plan addressing his PTSD. His initial assessment failed to gather specific information about the origin of his PTSD, its manifestations, triggers, or interventions. Staff members, including a CNA and RN, were unaware of R65's PTSD diagnosis and the necessary interventions, indicating a lack of communication and documentation regarding his mental health needs. The facility's policy on comprehensive care plans emphasizes the need for trauma-informed care, which was not reflected in the care plans for R41 and R65. The Director of Nursing and Social Worker acknowledged the deficiencies in the assessments and care plans, confirming that they should have included detailed information on the residents' PTSD, its manifestations, triggers, and personalized interventions. This oversight highlights a significant gap in the facility's approach to managing residents with PTSD, failing to meet their mental and psychosocial needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 5.71% error rate observed during a medication pass involving 35 opportunities. Two specific errors were identified. In the first instance, a Licensed Practical Nurse (LPN) was observed crushing and administering Januvia to a resident, despite the medication's label instructions stating it should not be split, crushed, or chewed. This action resulted in a dosing error for the resident, who had a physician's order for Januvia to be taken whole for the management of Type 2 diabetes mellitus without complication. In the second instance, another resident did not receive their prescribed dose of levothyroxine due to the medication not being available at the time of administration. The LPN acknowledged the absence of the medication, and it was later confirmed by the Director of Nursing (DON) that the medication was available in the Omnicell contingency supply and should have been administered. This oversight resulted in an omission error, as the resident's physician had ordered levothyroxine to be administered daily, excluding Sundays, for the treatment of hypothyroidism.
Failure to Promptly Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly resolve grievances for two residents, R40 and R34, as required by their grievance policy. R40, who has multiple sclerosis and is dependent on staff for all care, requested that her morning catheter flush be scheduled at 8:00 AM to allow her to attend activities and church on time. Despite this request, the facility consistently performed the flush after 9:00 AM, causing R40 to miss activities and be late for church. This grievance was voiced to the Nursing Home Administrator and Director of Nursing in August, but there was no documentation or follow-up on the grievance, and the issue persisted. R34 also experienced a delay in the resolution of her grievance. She reported receiving her bedtime medications late, and although the facility reeducated nurses on medication administration time frames, R34 was not informed of the resolution until four weeks later. This delay in communication violated the facility's policy, which states that residents should be informed of grievance resolutions in a timely manner. The facility's failure to document and address these grievances promptly indicates a lack of adherence to their grievance policy. The policy requires prompt efforts to resolve grievances, including acknowledging complaints and actively working towards a resolution. The facility's inaction in these cases resulted in ongoing issues for the residents, highlighting a deficiency in their grievance handling process.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, identified as R16, to the State Survey Agency. The incident involved a staff member telling R16 to "keep his mouth shut" after water was spilled on him and the floor. This incident was reported by another resident, R19, who overheard the exchange and noted the staff's tone was louder than normal. Both R16 and R19 reported the incident during a Resident Council Meeting, but the facility did not take the necessary steps to report the allegation to the Nursing Home Administrator or the state agency as required by their abuse policy. The facility's abuse policy mandates that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made. Despite this, the grievance investigation dated 11/5/24 showed that the facility did not report the incident to the state agency. The Director of Nursing and the Social Worker acknowledged the failure to report the allegation, and the Nursing Home Administrator was unaware of the incident until it was reviewed with the surveyor. This oversight indicates a lapse in the facility's adherence to its own policies regarding the reporting of abuse allegations.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency. This deficiency was identified for one of the three residents reviewed for abuse. A resident, R16, reported an incident where a staff member told him to keep his mouth shut after water was spilled on him and the floor. Another resident, R19, overheard this interaction and reported it to the staff and during a Resident Council Meeting. Despite these reports, the facility staff did not report the allegation of abuse to the Nursing Home Administrator or the state agency. The facility's abuse policy requires an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. However, the Director of Nursing and the Social Worker acknowledged that a thorough investigation was not conducted regarding this allegation of verbal abuse. The grievance investigation noted that R16 could not remember who the staff member was, and the resolution was to provide continual education to all staff. The Nursing Home Administrator also confirmed that the facility did not conduct a thorough investigation of the allegation.
Failure to Complete PASRR Level II for Extended Stay
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II for a resident who stayed longer than the initially anticipated short-term period. The resident, identified as R65, was admitted with several mental health diagnoses, including Schizotypal disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, and Major Depressive Disorder. Initially, a PASRR Level 1 screen was completed, indicating a short-term stay of 30 days or less, exempting the resident from a Level II screen. However, the resident remained in the facility beyond the 30-day exemption period without a subsequent Level II screen being conducted. The oversight was acknowledged by the facility's social worker and nursing home administrator, who admitted that the PASRR Level II screen should have been completed once it was clear the resident's stay would exceed 30 days. The failure to conduct the necessary screening was attributed to departmental turnover and changes in the electronic charting system, which led to the oversight. Despite the resident's continued stay in the facility, the required PASRR Level II screen was not performed, resulting in a deficiency.
Deficiencies in Resident Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to ensure a safe environment free from hazards and did not provide adequate supervision and assistive devices for two residents, leading to significant incidents. One resident, R2, who had severe cognitive impairment and a history of falls, was not transferred according to her care plan, which required the use of an EZ stand with one assist. Instead, a CNA performed a pivot transfer, resulting in R2 being lowered to the floor when her knees buckled. This incident led to R2 sustaining a left distal femur fracture, which required surgical intervention. The failure to follow the care plan was identified as neglect, and the involved staff member was terminated. Another resident, R1, who was at risk for elopement due to severe dementia, managed to leave the facility without staff awareness. R1 was wearing a WanderGuard, which failed to alarm when she exited the Memory Care Unit. She was found approximately 0.3 miles away from the facility by a witness. The facility's elopement and wandering policy was not effectively implemented, as staff did not notice R1's absence until she was reported missing. The investigation revealed issues with the WanderGuard system, including a malfunctioning antenna, which contributed to the failure to alert staff of R1's exit. Both incidents highlight deficiencies in the facility's adherence to care plans and supervision protocols. R2's care plan was not followed, leading to a preventable injury, while R1's elopement risk was not adequately managed, resulting in her unsupervised departure from the facility. These deficiencies indicate a lack of compliance with established safety and supervision policies, compromising resident safety.
Resident's Right to Refuse Medication Bypassed
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, was treated with dignity and respect, as required by regulations. R5, who has severe dementia with agitation, was subjected to physical restraint when a Med Tech (MT E) held R5's arms down to administer medication via an oral syringe. This action was taken despite R5's apparent refusal to take the medication, as evidenced by R5's combative behavior, including swinging arms and attempting to bite. The facility's policy on medication administration and dementia care emphasizes the importance of respecting residents' rights, including the right to refuse medication, which was not upheld in this instance. R5's medical history includes Alzheimer's disease, severe dementia with psychotic disturbance, and agitation, and the resident is under palliative care. The Minimum Data Set (MDS) indicates severe cognitive impairment and behavioral symptoms, including physical and verbal behaviors and rejection of care. Despite these documented behaviors, the facility staff did not adhere to the comprehensive care plan, which outlines strategies for managing R5's agitation and refusal of care, such as providing positive interaction, explaining procedures, and allowing the resident to adjust to changes. Interviews with facility staff, including MT E, MT F, RN K, and the Hospice Case Manager, revealed a lack of adherence to the resident's right to refuse medication. MT E admitted to bypassing R5's refusal by administering medication through an oral syringe, a method not authorized by the physician's orders. Other staff members acknowledged that using an oral syringe could bypass R5's right to refuse medication. The Director of Nursing confirmed that residents have the right to refuse medications, and using an oral syringe in this manner bypasses that right.
Failure to Conduct Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident. On 7/9/24, the facility reported the allegation to the state agency but did not complete a comprehensive investigation as required by their policy. The policy mandates immediate investigation, including identifying and interviewing all involved parties, such as the alleged victim, perpetrator, witnesses, and others with potential knowledge of the incident. However, the facility did not interview a potential witness identified by a CNA, nor did they interview the supervising nurse of the accused med tech or other staff who may have been involved or present during the incident. The surveyor's review on 8/1/24 revealed that the facility's investigation was incomplete, lacking interviews from key individuals who could provide relevant information about the alleged abuse. The Director of Nursing confirmed the absence of additional documented interviews and acknowledged that no audit or educational measures were associated with the allegation. This lack of thorough investigation and documentation constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as having increased exit-seeking behaviors. Despite the resident's initial assessment indicating no risk for elopement, subsequent behaviors such as wandering at night and expressing confusion were documented in the nurse's notes. These behaviors included looking for a way to leave the facility and expressing a desire to go home, which were not adequately addressed by the facility's staff. The resident eventually eloped from the facility, as noted in a self-report submitted by the Nursing Home Administrator. The report indicated that the resident was found outside the facility, attempting to find a police station. There was no documentation in the resident's electronic health record regarding the elopement, nor evidence of increased supervision or reassessment of the resident's elopement risk. The Director of Nursing confirmed that the facility's policy was not followed, as the resident's care plan did not include interventions for wandering or elopement risk, and the incident was not documented as expected.
Expired and Unlabeled Medications Found in Medication Carts
Penalty
Summary
The facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from medication carts. This deficiency was observed in 3 of 4 medication carts/storage rooms. Specifically, an expired Aspirin tablet was administered to a resident (R6) during medication administration. The resident had multiple diagnoses including hyperlipidemia, tachycardia, essential hypertension, diabetes mellitus type 2, asthma, and a pressure ulcer. The physician's orders required the administration of Aspirin 81 mg Enteric Coated (EC) daily. However, the Aspirin bottle used was unlabeled with no open date and had a manufacturing expiration date of 03/2024, which had already passed at the time of administration. Further observations revealed additional expired and unlabeled medications in other medication carts. For instance, the medication cart on the 600 wing contained an opened Aspirin bottle with an expired date, a Simethicone tab bottle with an expired date, and a Nitroglycerin bottle with no visible expiration date. Similar issues were found in the medication carts on the 100 and 300 wings. Interviews with the nursing staff and the Interim Director of Nursing (DON) confirmed that the facility's policy required labeling bottles with the open date and checking expiration dates before administration, but these procedures were not consistently followed. The DON acknowledged the need for improvement and indicated that medication carts were not being monitored consistently.
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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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