Oak Park Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 718 Jupiter Drive, Madison, Wisconsin 53718
- CMS Provider Number
- 525266
- Inspections on file
- 25
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 40 (3 serious)
Citation history
Health deficiencies cited at Oak Park Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with diabetes, venous insufficiency, neutropenia, obesity, and multiple lower-extremity wounds had physician orders for BID wound care to both feet and legs, bilateral tubi grips for edema, and routine Calmoseptine skin treatment. On one morning shift, the MAR showed these ordered treatments were not administered, and there was no documentation of provision or refusal of care. RNs and the DON confirmed that nurses are responsible for wound care and must sign out completed treatments in the EHR, including refusals, but no additional documentation was available for that shift.
A resident with dementia and other psychiatric diagnoses, who is rarely or never understood per MDS, was observed in a wheelchair with a nitroglycerin patch stuck to the wheelchair wheel, despite having no order for nitroglycerin. An RN confirmed the patch was dated from the prior day and stated that only one other resident on the unit had an order for such a patch, which should have been removed the previous night. Both the RN and the DON described the facility’s required process for nitroglycerin patch disposal—folding the patch in half and placing it in a sharps container or immediately removing it in trash—and acknowledged that the patch found on the wheelchair wheel was not disposed of according to facility policy or accepted professional principles.
The facility failed to implement an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19. Several residents with confirmed respiratory infections, including those with severe cognitive impairment and significant comorbidities, had no physician orders for transmission-based precautions and no care plan interventions addressing their infections. Isolation signage was missing from rooms of infected residents, and visitors entered without performing hand hygiene or using PPE. The IP was absent, and the DON and ADON reported they could not access or interpret the EMR infection tracking system, were not systematically tracking infected or non-infected residents’ respiratory symptoms, and had not entered isolation or droplet precaution orders or related care plans for affected residents. Requested outbreak documentation, including line listings, an outbreak management plan, and ongoing symptom tracking, could not be produced, and EMR infection control records showed the outbreak status and contact tracking had not been updated for several days despite multiple residents and staff reporting respiratory symptoms. These failures resulted in an immediate jeopardy finding under F880 for infection control.
The facility failed to designate and employ a qualified IP and had no trained back-up to manage the infection prevention and control program during an active outbreak of COVID-19, influenza, and RSV. The Regional Nurse identified as the IP had a job description focused on overall operations rather than IP duties, and the DON and ADON, who assumed responsibility in the IP’s absence, reported they were not trained as IPs, lacked access to the EMR infection tracking system, and could not interpret infection data. Outbreak documentation, including line listings, an outbreak management plan, and respiratory symptom tracking for non-infected residents, was not available, and electronic infection tracking had not been updated for several days. A resident with a history of stroke, a resident with Parkinson’s disease, and a resident with atrial fibrillation and a recent fracture developed respiratory symptoms and tested positive for influenza, RSV, or COVID-19, while rooms of infected residents lacked isolation/PPE signage, a visitor entered without hand hygiene or PPE, and housekeeping staff were unaware of the infections or required precautions.
Two residents, one cognitively intact with respiratory and cardiac conditions and one severely cognitively impaired with hypertensive heart disease and generalized anxiety disorder, were subjected to verbally abusive statements by an RN. The intact resident reported that when she requested her ordered narcotic pain medication, the RN called her "addicted," and that she witnessed the RN tell another resident to "stop your damn crying" while administering eye drops. The cognitively impaired resident, for whom the facility is home, could not be interviewed. The facility’s investigation documented these reports but the Administrator later stated he did not believe abuse occurred, despite an existing abuse-prevention policy guaranteeing residents freedom from abuse by staff.
A resident was subjected to verbal abuse by a family member, including yelling, swearing, and the throwing of a hanger, as witnessed and reported by others. Despite these reports, facility staff did not interview the resident, implement protective interventions, report the incident, or conduct an investigation, in violation of the facility's abuse prevention policies.
A resident was subjected to verbal abuse by a family member, witnessed by another resident and a visitor, who reported the incident to Social Services. Despite facility policy requiring immediate reporting of suspected abuse, the allegation was not reported to authorities, and no interventions were implemented to protect the resident.
A resident who was cognitively intact was subjected to verbal abuse by a family member, witnessed by another resident and a visitor. The incident was reported to Social Services and the administrator, but the facility did not conduct a thorough investigation, interview the resident, or implement interventions to ensure safety. The event was not reported to authorities as required by policy.
A resident under Enhanced Barrier Precautions did not receive proper infection control during wound care due to a nurse's failure to secure PPE and perform adequate hand hygiene. The nurse's gown repeatedly fell off, and the resident's foot contacted the nurse's mask and clothing, risking contamination. Interviews revealed gaps in staff training and adherence to infection control protocols.
A resident with intact cognition reported concerns about the cleanliness of her room, which was observed to have dust, debris, and stains on various surfaces, as well as a dark brown spill and spatter that remained unaddressed for several days. The Ancillary Director and facility leadership acknowledged the failure to maintain a clean environment, despite the resident's occasional refusal of chemical cleaners.
The facility failed to create comprehensive care plans for two residents prescribed Melatonin for insomnia, despite lacking a diagnosis of sleep disorders. Both residents received Melatonin daily without proper sleep assessments or evaluations of sleep hygiene. Interviews with staff confirmed the absence of necessary care plans and assessments, leading to the deficiency.
The facility failed to provide consistent and comprehensive wound care assessments for two residents with non-pressure injuries. One resident's wounds were not assessed weekly, and there were discrepancies in wound classification between the facility and external providers. Another resident's new wound was not fully assessed until days later. Technical limitations and inconsistent documentation practices contributed to the deficiency.
The facility failed to provide adequate care and documentation for two residents with pressure injuries. One resident had multiple pressure injuries that were not comprehensively assessed weekly, with inconsistencies in staging between the facility and the Wound Physician. Another resident developed pressure injuries that were misidentified as moisture-associated skin damage, and assessments lacked depth measurements. The facility's failure to follow its policy for weekly assessments and accurate documentation led to inadequate care.
A resident at high risk for falls did not have prescribed safety interventions, such as a low bed and fall mat, in place due to a printing error in the CNA care plan. The CNA was unaware of the resident's fall risk, leading to the absence of necessary precautions until the issue was identified by a surveyor.
Two residents were prescribed antipsychotic medications without appropriate diagnoses or updated consents. One resident received Quetiapine for dementia, and another was given Risperidone for anxiety, both of which are not appropriate indications. Additionally, the consent for an antidepressant was outdated, violating the facility's policy requiring updated consents every 15 months.
Failure to Provide and Document Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care and skin treatments and to document them according to policy for one resident. The facility’s wound care policy requires documentation of the date and time wound care is given, any refusals and reasons, and the signature and title of the person recording the data. The resident was admitted with multiple significant diagnoses, including type 2 diabetes with diabetic polyneuropathy, neutropenia, venous insufficiency, and obesity, and had multiple wounds on both feet and lower extremities. The physician’s orders included Calmoseptine ointment to the buttocks, groin, and folds every morning and at bedtime and after each toileting episode; bilateral high tubi grips on in the morning and off at bedtime for edema; and multiple specific wound care treatments to the left foot toes, left lower extremity, right foot, and right lower extremity, all to be completed twice daily and as needed. On the morning shift of 1/18/26, the Medication Administration Record showed that these ordered treatments were not administered. There was no documentation that the Calmoseptine, tubi grips, or any of the ordered wound care treatments for the resident’s left foot toes, left lower extremity, right foot, or right lower extremity were provided during that shift. Interviews with multiple RNs and the DON confirmed that nurses are responsible for conducting wound treatments and dressing changes and that, when treatments are completed, they are expected to be signed out in the electronic health record, including documentation if a resident refuses treatment. No further documentation was provided to account for the missing wound care treatments on that morning shift.
Improper Disposal of Nitroglycerin Patch Found on Resident’s Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper disposal of a nitroglycerin transdermal patch in accordance with professional standards and facility policy. During observation in the dining area, a surveyor saw a resident seated in a wheelchair with an oval, paper-tape-like object stuck to the wheelchair wheel. On closer inspection, the object was identified as a nitroglycerin patch labeled with a date of 2/3. Review of the resident’s physician orders confirmed that this resident did not have an order for nitroglycerin. The resident’s diagnoses include dementia, major depressive disorder, and schizophrenia, and the most recent MDS indicated that a BIMS could not be completed because the resident was rarely or never understood. When interviewed, an RN stated that only one resident on the unit had an order for a nitroglycerin patch and that the ordered patch would have been removed the previous night. The RN described the facility’s expected disposal process for nitroglycerin patches as folding the patch in half so the medicated sides adhere together and then placing it in a sharps container or wrapping it in gloves, placing it in the resident’s trash, and immediately removing the trash. The RN acknowledged that the patch found on the wheelchair wheel had not been properly disposed of. The DON similarly stated that nitroglycerin patches should be folded on themselves and placed in a sharps container and agreed that the patch observed on the wheelchair wheel was not properly disposed of, indicating noncompliance with the facility’s medication disposal policy and accepted professional principles.
Failure to Implement Effective Infection Control During Concurrent Influenza, RSV, and COVID Outbreaks
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19, affecting residents, staff, and visitors. The facility did not ensure appropriate physician orders or care plans were in place for multiple residents with confirmed respiratory infections, including influenza, RSV, and COVID. For one resident with a history of stroke and severe cognitive impairment who tested positive for both influenza and RSV, there were no orders addressing management of these infections and no care plan interventions, despite documented respiratory symptoms and positive lab results. This resident’s room lacked any droplet precaution signage, and a visitor entered and exited the room multiple times without performing hand hygiene or using PPE, with staff confirming the absence of signage indicating required precautions. Another resident with Parkinson’s disease and severe cognitive impairment developed respiratory symptoms and later tested positive for influenza. Although a nurse’s note referenced discussion with the NP about Tamiflu and isolation time frames, the comprehensive physician order set contained no orders for transmission-based precautions, and the care plan did not address influenza management. This resident, who had an active order for Tamiflu, also had no droplet precaution signage on the room door. A third resident with dysphagia and a history of sepsis tested positive for influenza, yet had no related physician orders for infection management or TBP and no care plan addressing influenza. A fourth resident, cognitively intact and positive for COVID, had droplet precaution orders in place but no corresponding care plan for COVID management. A fifth resident with vascular dementia and dysphagia tested positive for COVID, but had no droplet precaution orders until several days after symptom onset and no care plan addressing COVID. The facility’s leadership and infection control infrastructure were also deficient. The designated IP was not present in the facility during key survey dates and was unavailable for interview. The DON reported that she and the ADON were responsible for infection control when the IP was absent but stated they could not access or interpret the EMR infection tracking system and had only basic infection control training. The DON acknowledged she was not tracking residents with influenza, RSV, or COVID in an organized manner and was not tracking respiratory symptoms in non-infected residents. She also confirmed that isolation and droplet precaution orders and related care plans had not been entered for residents on droplet precautions for influenza, COVID, and RSV, and that symptom tracking for respiratory illness in all residents had not been occurring prior to a later date. When surveyors repeatedly requested outbreak documentation, including line listings, an outbreak management plan, and evidence of respiratory symptom tracking, the facility could not provide an outbreak management plan or documentation showing systematic tracking of non-infected residents. Infection control documentation from the EMR showed the outbreak status had not been updated for several days, and contact tracking had not been documented beyond its initial entry, despite multiple residents and staff reporting respiratory symptoms during the outbreak. The Administrator and DON were unable to produce an outbreak management plan for the concurrent influenza and COVID outbreaks when interviewed. The DON stated she did not know why droplet precaution signage was missing from the doors of infected residents and reiterated that her expectation was that such signage should be present. A Regional Nurse Consultant confirmed that his expectation for outbreak management included appropriate documentation such as line listings, a functioning outbreak management plan, symptom tracking for staff and residents, and family notification of infection and outbreak status, but the facility lacked this documentation. The combination of missing orders and care plans for infected residents, absent or unclear isolation signage, lack of organized surveillance and tracking, and limited infection control oversight led to the determination of immediate jeopardy related to infection control. The facility’s own policies required prompt identification and management of communicable disease outbreaks, defined thresholds for declaring an outbreak, and assigned responsibilities to the administrator, IP, DON, and staff for surveillance, initiation of transmission-based precautions, and communication with health authorities and families. Policies also required that when residents are placed on transmission-based precautions, appropriate notification be placed on the room entrance door and chart, and that visits to residents on influenza precautions be scheduled and controlled with instruction on hand hygiene and PPE. Despite these written policies, the facility did not implement them during the concurrent outbreaks, as evidenced by the lack of isolation signage, absence of documented TBP orders and care plans for multiple infected residents, and failure to maintain up-to-date outbreak tracking and symptom surveillance. Staff symptom logs provided to surveyors showed multiple employees, including activity aides, housekeepers, CNAs, and an RN, reporting respiratory or flu-like symptoms over several days during the outbreak period. However, there was no evidence that this information was integrated into a broader outbreak management or surveillance system. The EMR infection control management system showed that outbreak status had not been evaluated or updated for several days, and contact tracking documentation had not been continued after its initial entry. These inactions, combined with the absence of a functioning outbreak management plan and the lack of systematic tracking of both infected and non-infected residents, contributed directly to the identified deficiency in the facility’s infection prevention and control program. Overall, the deficiency centers on the facility’s failure to operationalize its infection control policies and CDC-based guidance during simultaneous outbreaks of influenza, RSV, and COVID. This included not ensuring that residents with confirmed infections had appropriate physician orders and individualized care plans, not posting required isolation signage, not maintaining organized surveillance and outbreak tracking, and not having adequately trained and available infection control leadership to manage the situation. These documented failures led surveyors to determine that immediate jeopardy existed under F880 for infection control.
Failure to Designate Qualified Infection Preventionist and Manage Respiratory Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a qualified Infection Preventionist (IP) to develop, implement, and monitor the infection prevention and control program, including during an active outbreak of COVID-19, influenza, and RSV. The facility identified a Regional Nurse as the IP, reportedly working 20 hours per week, but the Regional Nurse’s job description focused on overall facility operations and only generally referenced following established infection control procedures. The facility lacked a qualified back-up IP, and the designated IP was not present in the facility and unavailable for interview during multiple days of the survey while the outbreak was ongoing. During the IP’s absence, the DON and ADON reported they were responsible for managing the infection control program and the current outbreak, but both confirmed they were not trained as IPs, could not interpret the IP’s information, and could not act on her behalf. They also stated they did not have access to the EMR Infection Tracking Program and would not be able to read or understand the information even if they obtained access. The surveyors requested outbreak-related documentation multiple times, including staff and resident line listings, an outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents, but the facility could not provide an outbreak management plan or documentation showing tracking of non-infected residents. Infection control documentation from the facility’s PCC Infection Control Management System showed that outbreak status had not been evaluated, tracked, or updated for several days, and contact tracking documentation had not been updated since the date it was initiated. The deficiency also included specific resident-level findings and infection control lapses. One resident with a history of stroke developed respiratory symptoms and later tested positive for both influenza and RSV, another resident with Parkinson’s disease developed respiratory symptoms and tested positive for influenza, and a third resident with atrial fibrillation and a recent pubic bone fracture developed respiratory symptoms and tested positive for COVID-19. Surveyors observed that required isolation/PPE signage was not posted outside the rooms of residents with RSV and/or influenza. A visitor entered and exited one such resident’s room multiple times without performing hand hygiene or donning PPE, and housekeeping staff reported they were unaware of the residents’ infectious status or required PPE and confirmed there were no signs at the doorways directing them on precautions.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a registered nurse, contrary to its abuse prevention policy that guarantees residents the right to be free from abuse by anyone, including staff. One resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including acute and chronic respiratory failure and heart disease, reported that during the night she requested her ordered narcotic pain medication and the RN responded by referring to her as "addicted." The same resident also reported that on the previous evening she witnessed the RN administering eye drops to another resident and telling that resident to "stop your damn crying" when the resident cried during the procedure. The second resident involved, whose diagnoses included hypertensive heart disease and generalized anxiety disorder and who had a BIMS score of 6 indicating severe cognitive impairment, was described as considering the facility her home and could not be interviewed due to poor cognition. The facility’s own incident reporting and investigation documentation reflected that an investigation into potential verbal abuse of both residents was initiated after the cognitively intact resident reported these events. During a subsequent interview with surveyors, the cognitively intact resident reiterated that she felt verbally abused when called "addicted" and believed the other resident was verbally abused when told to stop her "damn" crying. The Administrator later stated he did not feel either resident was abused and characterized the situation as a "he said/she said" matter, despite the facility’s policy requiring protection from abuse.
Failure to Implement Abuse Prevention Policies Following Family Member's Verbal Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after being made aware that a family member verbally abused a resident—including yelling, swearing, and throwing a hanger in the resident's room—the facility did not take steps to protect the resident from further abuse, did not report the incident, and did not conduct an investigation as required by their abuse prevention policy. Witnesses, including another resident and a visitor, reported the incident to Social Services, describing the family member's behavior as abusive and distressing. Despite these reports, the facility did not interview the resident involved, citing the family member's status as activated power of attorney and their instruction that staff could not speak to the resident without their presence. Staff acknowledged the incident could be considered abuse and confirmed that no interventions or plans were put in place to ensure the resident's safety. The facility also failed to report or thoroughly investigate the allegation, contrary to their own policies and federal requirements.
Failure to Timely Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident and a family member was reported to the appropriate authorities within the required timeframe. On the date of the incident, a family member was observed by another resident and a visitor yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to the facility's Social Services staff, who in turn reported it to the previous Nursing Home Administrator. Despite the facility's policies requiring immediate reporting of suspected abuse to local, state, and federal agencies, the allegation was not reported as required. The resident involved was cognitively intact, as indicated by a recent BIMS score. Staff did not interview the resident about the incident due to instructions from the family member, who was the activated power of attorney, that staff could not speak to the resident without her present. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the facility did not report the allegation to the appropriate agencies as mandated by policy and regulation.
Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported and thoroughly investigated according to state law and facility policy. On 10/22/25, an allegation of verbal abuse by a family member toward a resident was reported to the facility. Witnesses, including another resident and a visitor, described hearing and seeing the family member yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to Social Services, who in turn reported it to the previous Nursing Home Administrator. Despite these reports, the facility did not conduct a thorough investigation, did not interview the resident involved, and did not obtain written witness statements as required by policy. The resident involved was cognitively intact, as indicated by a recent BIMS score of 13. Staff cited the family member's status as activated power of attorney as a reason for not interviewing the resident, stating that the family member required to be present for any staff interaction with the resident. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the incident was not reported to the appropriate authorities as required by federal and state regulations. The facility's inaction was confirmed by both Social Services and the current Nursing Home Administrator during interviews.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) and inadequate hand hygiene practices by a Registered Nurse (RN) during the treatment of a resident. The resident, who was under Enhanced Barrier Precautions due to conditions including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Peripheral Vascular Disease, required specific infection control measures during wound care. However, the RN did not secure the gown properly, leaving it open in the back, and repeatedly allowed it to fall off the shoulders during the procedure, compromising the protective barrier. Throughout the treatment, the RN failed to maintain proper hand hygiene, performing handwashing for significantly less than the recommended 20 seconds. The RN's gown frequently fell off, and at one point, the resident's foot with an old dressing touched the RN's N95 mask, stethoscope, and clothing, leading to potential contamination. Despite these issues, the RN continued the procedure without addressing the gown's fit or the contamination risk. Interviews with the RN and the Director of Nursing (DON) revealed a lack of awareness and adherence to proper infection control protocols. The RN admitted the gown did not fit properly and had not reported this issue to the DON. Additionally, there was a discrepancy in the understanding of the required duration for hand hygiene, with the RN and DON providing incorrect information. These lapses in infection control practices highlight deficiencies in staff training and adherence to established policies, potentially compromising resident safety.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R31, as evidenced by multiple observations of unclean conditions in her room. R31, who has intact cognition with a BIMS score of 15 out of 15, expressed concerns about the cleanliness of her room. Observations by the surveyor on multiple occasions revealed dust-coated window blinds, debris and stains on window sills, dust on shelving, dried liquid stains on the bedside table, and debris on the floor. Additionally, a dark brown spill and spatter were noted under the bed and on the wall behind the bed, as well as near the door and the dirty linen collection bin. The Ancillary Director acknowledged that the room should have been cleaned more frequently and that the dark brown spill/spatter should have been addressed immediately. It was noted that R31 sometimes refused the use of chemical cleaners, but alternative cleaning methods such as using a dust cloth or soap and water were not employed. The Nursing Home Administrator and Director of Nursing also confirmed that the room should not have remained in such a state for six days and that housekeeping should have been maintaining cleanliness regularly.
Failure to Develop Comprehensive Care Plans for Residents on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents who were prescribed Melatonin for insomnia, despite neither having a diagnosis of insomnia or any other sleep disturbance disorders. Resident 9, with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder, was receiving Melatonin daily without a documented sleep assessment or evaluation of sleep hygiene. Similarly, Resident 42, diagnosed with Alzheimer's disease and dementia, was also receiving Melatonin daily without an up-to-date sleep assessment or evaluation of sleep hygiene. The facility's care plans for both residents lacked documentation regarding the use of Melatonin for insomnia and did not include monitoring of sleep hygiene or the medication's effectiveness. Interviews with facility staff, including the Registered Nurse Unit Manager and the Director of Nursing, revealed an acknowledgment of the deficiency. Both staff members indicated that the residents should have had care plans related to sleep, including monitoring of sleep hygiene and the effectiveness of Melatonin. Additionally, they acknowledged that sleep assessments should be conducted quarterly or at least annually, but these assessments were not completed for the residents in question. The lack of a comprehensive care plan and failure to conduct necessary assessments led to the deficiency identified by the surveyors.
Inconsistent Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services consistent with professional standards of practice, specifically for two residents with non-pressure injuries. One resident, with a history of multiple medical conditions including peripheral vascular disease and chronic osteomyelitis, had several non-pressure injuries that were not comprehensively assessed weekly. The documentation for the location and etiology of these injuries was inconsistent between the facility and the Wound Physician. The facility's records often lacked depth measurements, and there were periods where no weekly assessments were documented. Additionally, there was confusion regarding the classification of wounds as pressure or non-pressure, leading to conflicting documentation between the facility and external wound care providers. Another resident developed a non-pressure injury that was not comprehensively assessed until several days after its initial documentation. The resident, who had a history of diabetes and other significant health issues, was noted to have a new blister and an open area near the rectum, which was not fully assessed until seen by the Wound Physician. The facility's process for wound assessment was hindered by technical limitations, such as a camera system that did not measure wound depth, and there was a lack of manual documentation to compensate for these limitations. The facility's failure to conduct comprehensive and consistent wound assessments, along with discrepancies in wound classification and documentation, contributed to the deficiency. The nursing staff, including a registered nurse who was not wound care certified, did not consistently review or align their documentation with that of the Wound Physician or the wound clinic, leading to ongoing issues in the management and treatment of the residents' wounds.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents with pressure injuries. One resident, identified as R7, had multiple pressure injuries, including a Stage 4 pressure injury to the left heel, a Stage 4 pressure injury to the left lateral foot, and a Stage 3 pressure injury to the left first toe. The facility did not comprehensively assess these wounds weekly, and there were inconsistencies in the documentation of the staging of the pressure injuries between the facility and the Wound Physician. The facility's documentation often lacked depth measurements, and the staging was not accurate according to the Wound Physician's assessments. Another resident, identified as R12, developed a Stage 2 pressure injury to the sacrum, which was not comprehensively assessed until a week later when seen by the Wound Physician. The facility's documentation incorrectly identified the wound as moisture-associated skin damage (MASD) rather than a pressure injury, as documented by the Wound Physician. Additionally, R12 developed a Stage 2 pressure injury to the right thigh, which was also not comprehensively assessed until several days later. The facility's documentation continued to misidentify the etiology of the wounds, and there were no depth measurements recorded. The facility's failure to accurately assess and document the pressure injuries led to a lack of consistent and appropriate care for the residents. The facility's policy required weekly assessments of pressure injuries, but this was not consistently followed. The use of a camera for wound assessments was cited as a reason for missing depth measurements, but manual measurements were not taken when the camera was not functioning. The discrepancies between the facility's documentation and the Wound Physician's assessments contributed to the deficiency in care provided to the residents.
Failure to Implement Fall Risk Interventions for a Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent accidents for a resident identified as R5, who was at high risk for falls. R5 had a history of transient cerebral ischemic attack, essential tremor, and dementia with severe cognitive impairment. The care plan for R5 included interventions such as a low bed and a fall mat to mitigate the risk of falls. However, during an observation, it was noted that these interventions were not in place while R5 was in bed. The bed was not in the lowest position, and the fall mat was not next to the bed, contrary to the care plan requirements. The deficiency was further highlighted when a CNA, responsible for R5's care, was unaware of the fall risk interventions due to a printing error in the CNA care plan sheets. The CNA care plan did not list R5 as a fall risk, leading to the absence of necessary safety measures. Upon inquiry, the CNA found the fall mat in R5's bathroom and placed it next to the bed, and subsequently lowered the bed to the correct position. The RN and RNUM confirmed the oversight, attributing it to a printing error that omitted the fall interventions from the CNA care plan sheets for that day.
Inappropriate Use of Psychotropic Medications and Lack of Consent
Penalty
Summary
The facility failed to ensure that residents using psychotropic drugs had appropriate assessments, diagnoses, and consent, affecting two residents. One resident, identified as R9, was prescribed Quetiapine Fumarate, an antipsychotic, for dementia, which is not an appropriate indication for such medication. This resident was admitted with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder. The facility's policy on psychotropic medication use requires that medications be clinically indicated to treat a specific condition, which was not adhered to in this case. Another resident, R42, was prescribed Risperidone, an antipsychotic, for anxiety, and Citalopram, an antidepressant, without active consent. R42 was admitted with Alzheimer's disease, dementia, and anxiety disorder, but did not have a diagnosis of insomnia or sleep disturbance disorders. The consent for Citalopram was outdated, having been signed over 15 months ago, and the facility's policy requires consents to be updated every 15 months. Interviews with the Registered Nurse Unit Manager and the Director of Nursing confirmed the lack of appropriate diagnosis and consent for the antipsychotic medications prescribed to these residents.
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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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