Odd Fellow Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Bay, Wisconsin.
- Location
- 1229 S Jackson St, Green Bay, Wisconsin 54301
- CMS Provider Number
- 525559
- Inspections on file
- 25
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Odd Fellow Home during CMS and state inspections, most recent first.
A resident with post-hip arthroplasty, osteoarthritis, and atrial fibrillation had a clarified order for Eliquis to be given at 2.5 mg BID for one week, then increased to 5 mg BID. Although the clarification was documented and the family was informed, staff continued to administer 2.5 mg BID for an additional day, and the MAR showed the 5 mg BID dose was not started until the following day. This discrepancy, attributed by the NHA to a possible transcription error, resulted in two incorrect Eliquis doses and was not consistent with the facility’s medication administration policy requiring adherence to prescriber orders.
The facility did not report two separate allegations of abuse involving two residents to the State Agency as required. In one case, a resident's abuse-related fall investigation was not submitted within the mandated timeframe, and in another, a resident's report of rough handling by a CNA was handled as a grievance but not reported to the SA.
Two residents' abuse allegations were not thoroughly investigated, as required by facility policy. In one case, a resident's fall determined to be abuse lacked statements from the involved CNA and LPN, and staff education did not match the resident's care plan. In another case, a resident reported being manhandled by a CNA, but the investigation was incomplete, missing root cause analysis, interviews, and documentation of staff education.
A resident with multiple medical conditions, including epilepsy, did not receive scheduled AM and PM medications within the required time frame on several occasions. Facility policy requires medications to be administered within one hour of the prescribed time, but MAR review and staff interviews confirmed repeated late administration, and the resident reported ongoing concerns about medication delays.
A resident with severe cognitive impairment, muscle weakness, and a history of repeated falls did not consistently receive prescribed fall prevention interventions, including 15-minute safety checks and grip strips at the bedside. Staff failed to complete safety checks for several hours, during which the resident experienced an unwitnessed fall with injury. Observations and staff interviews confirmed that interventions were not reliably implemented or documented, despite facility policy and the resident's high risk status.
The facility did not have a qualified IP overseeing the infection prevention and control program, as neither the interim IP nor the DON had completed required specialized training. During this period, staff returned to work before meeting CDC recommendations after COVID-19 or GI illness, and the facility lacked policies specifying IP training requirements or hours needed for the role.
Surveyors found that medications and biologicals were not consistently labeled, dated, or stored according to policy. Multiple medications, including inhalers, insulin, and eye drops, were found without open dates or labels, and expired medications and supplies were present in storage areas and on medication carts. Staff, including LPNs and the DON, confirmed these deficiencies during interviews, acknowledging that medications should be dated when opened and expired items should be removed.
Multiple staff failed to use appropriate PPE and follow infection control protocols during care of residents on enhanced barrier precautions, including wound care and equipment sanitation. Additionally, staff returned to work after COVID-19 or GI illness earlier than CDC and state guidelines recommend, with incomplete documentation of symptom resolution.
Two residents with suspected serious mental illness were granted 30-day hospital exemptions on their PASRR Level I Screens, but the facility did not submit the required PASRR Level II Screens after the exemptions expired. One resident had anxiety disorder and was not cognitively impaired, while the other had multiple mental health diagnoses and moderate cognitive impairment. The Admissions Coordinator confirmed the oversight.
A resident receiving hemodialysis was not consistently monitored for bruit/thrill as required by facility policy, and there was a lack of ongoing communication between facility staff and the dialysis center. Staff interviews revealed that daily monitoring was not documented, and there was confusion about what information was exchanged with the dialysis center, resulting in incomplete records and missing aftercare instructions.
A nurse administered Senna-Plus, a combination laxative, instead of the prescribed Senna to a resident during a medication pass. Facility policy requires staff to verify medications against prescriber orders, but this step was not followed, resulting in the resident receiving the incorrect medication.
Three residents received antibiotics without meeting McGeer's criteria for infection, and prescribers were not notified of the lack of qualifying signs or symptoms. The facility did not follow its own antibiotic stewardship policies, resulting in inappropriate antibiotic use for urinary, skin, and respiratory infections.
The facility failed to update care plans for three residents regarding the use of Hoyer slings, which were left under residents in Geri chairs and wheelchairs, contrary to facility policy. Despite the policy requiring sling removal, staff routinely left them in place, and care plans lacked necessary updates. Observations and interviews confirmed this practice, with residents reporting no discomfort, but the facility's policy was not followed.
A resident with hemiplegia and an acquired absence of the right leg was left hanging in a lift due to a dead battery during a transfer. Staff interviews revealed that lift batteries often died mid-transfer, and staff did not consistently check battery life. The facility had ordered new batteries, but only one was observed in the charger. The Nursing Home Administrator confirmed that staff should use a manual release to lower residents if a battery dies, but this was not done, resulting in the resident being left suspended.
Two residents with indwelling catheters had their catheter drainage bags improperly placed in contact with the floor, contrary to the facility's policy. One resident's bag was on the floor due to the bed's position, while another's bag was dragging on the floor from their wheelchair. Staff confirmed the improper placement, highlighting a lapse in infection control procedures.
A resident with type 2 diabetes on a CCHO diet received a full piece of cake instead of the prescribed half piece. The dietary staff provided the larger portion based on the resident's preference, despite the meal ticket indicating a smaller serving. The facility lacked a policy to ensure adherence to prescribed diets, leading to this inconsistency.
A resident on Enhanced Barrier Precautions did not receive proper infection control measures as staff failed to wear PPE during high-contact care and did not disinfect equipment after use. Despite the resident's significant medical history, including severe sepsis and open wounds, staff did not adhere to the facility's infection control policies.
The facility failed to timely report and investigate an altercation between two residents, one with intact cognition and another with severe cognitive impairment. The incident was not reported to administration promptly, leading to a delay in notifying the State Agency. Additionally, there was no proof of education for certain staff on duty during the incident, indicating a lapse in staff training on reporting requirements.
The facility failed to ensure proper disposal of garbage and refuse in outside dumpsters. During a kitchen tour, three dumpsters were found with open lids and garbage on the ground. The Dietary Manager acknowledged the issue but did not take immediate action to remove the garbage.
The facility failed to honor the meal preferences of six residents, providing meals that did not match dietary plans or preferences. Staff made assumptions about residents' choices without consulting them or their power of attorney for healthcare.
The facility failed to provide timely written transfer notices to three residents and did not notify the State Long-Term Care Ombudsman of these transfers. The residents were transferred to the hospital for various medical reasons, but the required documentation and notifications were not completed as per the facility's policy.
The facility failed to provide three residents with written information regarding the bed hold policy when they were transferred to the hospital. This deficiency was confirmed by the Assistant Nursing Home Administrator and the Nursing Home Administrator, who indicated that nurses are expected to provide this information but did not do so in these cases.
The facility failed to ensure resident safety and proper fall management by using defective equipment, not completing fall assessments, and not updating care plans with new interventions. Despite warnings, a lift with broken brakes and a defective sling was used, and neurochecks were not completed as required.
A resident with obstructive sleep apnea was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not included in the care plan. The facility's policies for CPAP therapy and infection prevention were not followed, as evidenced by the lack of labeling on the CPAP machine's tubing and inconsistent staff education on the CPAP mask/machine.
The facility failed to ensure proper monitoring of a high-risk medication for a resident with diabetes mellitus. The resident's care plan lacked interventions to monitor for hypoglycemia and hyperglycemia, despite having physician orders for both short-acting and long-acting insulin. The deficiency was confirmed through a medical record review and an interview with the DON.
Failure to Accurately Transcribe and Implement Eliquis Dose Change
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration for one resident when staff did not follow the prescriber's clarified order for Eliquis dosing. The resident was admitted with diagnoses including post-hip arthroplasty, osteoarthritis, atrial fibrillation, and panic disorder, and had an MDS BIMS score of 15/15 indicating intact cognition. Hospital discharge paperwork ordered Eliquis 5 mg twice daily for DVT prevention, with instructions to give 2.5 mg twice daily for the first seven days post-operatively. A subsequent physician communication on 12/23/25 clarified that the resident should receive Eliquis 2.5 mg twice daily through 12/25/25 and 5 mg twice daily starting on 12/26/25, and a nursing note documented that the order was changed accordingly and the family was updated. Despite this clarification and documentation, the December MAR showed that the resident continued to receive Eliquis 2.5 mg twice daily from 12/19/25 through 12/26/25, totaling eight days at the lower dose, and the 5 mg twice daily dose was not started until 12/27/25. This resulted in the resident receiving two incorrect doses of Eliquis on 12/26/25, contrary to the prescriber's order and the facility's Administering Medications policy, which requires medications to be administered in accordance with prescribers' orders. During interview, the NHA confirmed that the Eliquis dose should have been increased on 12/26/25 and acknowledged that a transcription error may have occurred when the order was entered.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (SA) for two residents as required by policy and federal regulations. In the first instance, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls experienced a witnessed fall. The Interdisciplinary Team determined that abuse had occurred based on the LPN's progress note. While the initial report was submitted to the SA on the day of the incident, the required 5-day investigation report was not submitted within the mandated timeframe, as the Nursing Home Administrator delayed submission while waiting for an additional staff statement. In the second instance, another resident with intact cognition and a history of congestive heart failure, respiratory failure, and falls reported to staff that a CNA was abusive during care, describing rough handling and feeling unsafe. The facility initiated a grievance form and provided staff education, but did not report the abuse allegation to the SA as required. The Nursing Home Administrator later verified that this allegation should have been reported.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents. In the first case, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls, experienced a witnessed fall. The facility determined that abuse had occurred based on a progress note from an LPN. However, the investigation was incomplete as it did not include statements from the involved CNA or LPN. Additionally, the staff education provided after the incident was inaccurate, as it did not reflect the resident's care plan requirements for transfer assistance, and only a fraction of employees signed the education documentation. In the second case, another resident with intact cognition and a history of falls and other medical conditions reported that a CNA was abusive, describing being manhandled and treated rudely during care. The grievance was documented, but the investigation did not follow facility policy, as it lacked immediate action, root cause analysis, interviews with other potentially affected residents, and witness statements from involved staff. There was also no documentation of staff education signatures or further investigative records related to this allegation. Both incidents demonstrate that the facility did not adhere to its own policies regarding the immediate and thorough investigation of abuse allegations. Required investigative steps, such as obtaining statements from all involved parties and ensuring accurate staff education, were not completed, resulting in deficiencies in the facility's response to reported abuse.
Failure to Administer Medications Timely per Physician Orders
Penalty
Summary
A deficiency was identified when a resident's medications were not administered in accordance with physician orders and facility policy. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified. Record review and staff interviews revealed that a resident, who had diagnoses including osteomyelitis, epilepsy, peripheral vascular disease, depression, and osteoarthritis, experienced multiple late administrations of both morning and evening medications. The resident, who was cognitively intact and their own decision maker, reported to the surveyor that their medications, including antiepileptic drugs, were late most days and specifically had not been received by the expected time on the day of the survey. Review of the Medication Administration Record (MAR) showed that the resident's scheduled 8:00 AM medications were administered late on at least seven occasions, with administration times ranging from 9:10 AM to 10:06 AM. Additionally, an evening medication scheduled for 8:00 PM was administered at 11:04 PM on one occasion. Staff interviews confirmed that the nurse was running late with the medication pass and that the resident had expressed concerns about the timeliness of medication administration. The Nursing Home Administrator also acknowledged the facility's policy regarding the one-hour window for medication administration.
Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to consistently implement fall prevention interventions for a resident assessed as high risk for falls. The resident had a history of repeated falls, cognitive impairment, muscle weakness, and required substantial assistance with mobility and activities of daily living. The care plan included interventions such as fifteen-minute safety checks while sleeping and grip strips on the floor near the bed, but these were not reliably carried out. Specifically, safety checks were not completed for over three hours on one occasion, during which the resident experienced an unwitnessed fall resulting in head lacerations. Additionally, grip strips were not present at the bedside during observations, and staff confirmed these were not placed after the resident changed rooms. Staff interviews revealed inconsistent implementation and documentation of the prescribed interventions. The DON and ADON acknowledged that grip strips were not installed in the new room and that 15-minute safety checks were not always performed or properly documented. The ADON also indicated that the checks were not consistently listed as care plan interventions and that CNAs did not always follow the intended protocols. Observations further showed the resident was at risk while seated in a Broda chair, with poor posture and sliding down, requiring staff assistance. The facility's own policy required staff to identify and implement interventions based on the resident's specific risks and to monitor and adjust these interventions as needed. Despite the resident's high fall risk and documented history of falls, the facility did not ensure that the care plan interventions were consistently in place or that staff adhered to the established protocols, leading to preventable lapses in supervision and safety.
Failure to Ensure Qualified Infection Preventionist and Adequate Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was responsible for the infection prevention and control program, as required by CMS regulations. After the previous IP left unexpectedly, the facility assigned IP duties to IP-C and the DON, but neither had completed the required specialized training in infection prevention and control. IP-C had started the CDC IP training modules but had only completed 10 out of 24 modules, while the DON had not begun any IP training. The newly hired IP had just started training and was not yet qualified. The facility also lacked an infection prevention and control policy that described the IP's training requirements or specified the number of hours needed for the IP role. Surveyor interviews and record reviews revealed that, during this period, there were multiple instances where staff returned to work before meeting CDC recommendations following COVID-19 or gastrointestinal illness. Additionally, the facility assessment did not specify the required hours for the IP position, and there were gaps in the infection prevention process due to the absence of a trained IP. The facility did not have a trained IP available to train the new IP, further contributing to deficiencies in the infection prevention and control program.
Medication Labeling, Dating, and Storage Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were properly labeled, dated, and stored according to professional standards and facility policy. During observations, multiple instances were noted where medications, including inhalers, insulin, eye drops, and supplements, lacked open dates or were left unlabeled. For example, an LPN confirmed that a Med Pass 2.0 supplement on the medication cart was not dated when opened, and an RN acknowledged leaving medication unattended on top of a medication cart in the hallway. Additionally, several residents' medications, such as inhalers and insulin, were found without required open dates, despite pharmacy labels specifying expiration periods after opening. Further inspection of medication storage areas revealed the presence of expired and undated medications and medical supplies. Surveyors found numerous expired items, including vacutainer devices, lubricating jelly packets, blood tubes, syringes, and skin repair cream, as well as undated and open medication packages for several residents. Staff interviews confirmed that these items were expired and should have been removed from storage. The facility's policies require that expired or discontinued medications be returned or destroyed and that all medication storage compartments remain locked and not left unattended. Additional deficiencies were observed on medication carts, where open, unlabeled, and undated medications and supplies were found, including inhalers, nasal sprays, eye drops, and other treatments. Staff interviews with LPNs and the DON confirmed that medications such as eye drops, inhalers, and nebulizer packets should be dated when opened and that expired items should be disposed of. Despite the facility's stated practice of conducting audits and checking dates before use, these lapses in medication management were directly observed during the survey.
Failure to Implement and Enforce Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Several staff members did not use appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP), including during transfers, hygiene, and wound care for a resident with chronic diabetic wounds. The resident's room initially lacked EBP signage, and staff were observed assisting the resident without PPE, despite the facility's policy requiring gloves and gowns for high-contact care activities. Additionally, staff knelt on the floor during wound care without using a barrier, contrary to infection control protocols. Another resident on EBP for an ankle infection did not receive care in accordance with PPE requirements. A registered nurse assessed the resident's foot without gloves or a gown and later stated that PPE was only necessary for toileting, not for wound assessment, indicating a lack of understanding of EBP protocols. Furthermore, staff failed to sanitize blood pressure equipment and a stethoscope after use on a resident, and the nurse acknowledged that the equipment should have been sanitized but did not do so. The facility also did not adhere to CDC and Wisconsin Department of Health Services guidelines regarding staff return-to-work criteria following COVID-19 or gastrointestinal illness. Staff with COVID-19 or GI symptoms returned to work earlier than recommended, and the facility's documentation did not consistently record the date of last symptoms, making it difficult to verify compliance. The infection line lists and time clock records provided did not include necessary information to ensure staff met the required exclusion periods before returning to work.
Failure to Submit PASRR Level II Screens After 30-Day Hospital Exemption Expired
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) Level I Screen was followed by a Level II Screen when the 30-day hospital exemption expired for two residents. Both residents were identified as suspected of having a serious mental illness on their PASRR Level I Screens and were granted a 30-day hospital exemption. However, after the expiration of the exemption, there was no evidence in the medical records that a PASRR Level II Screen was submitted for either resident. One resident had a diagnosis of anxiety disorder and was prescribed Ativan, with a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment. The other resident had diagnoses of insomnia, depression, and anxiety disorder, was prescribed multiple psychotropic medications, and had a BIMS score indicating moderate cognitive impairment. The Admissions Coordinator confirmed responsibility for completing PASRRs and acknowledged that the required Level II Screens were not submitted after the exemptions expired.
Failure to Ensure Ongoing Dialysis Communication and Fistula Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center and did not consistently monitor the fistula site for a resident who required hemodialysis. The resident, who had diagnoses including dementia, anxiety, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy, received dialysis three times weekly. Facility policy required daily monitoring of the fistula or graft for pulse, buzzing, or thrill, and regular checks for patency. However, the resident's care plan and Medication Administration Record did not reflect daily monitoring for bruit/thrill, and only eight dialysis communication entries were documented over an eight-month period. Staff interviews confirmed that monitoring for bruit/thrill was not included in the resident's MAR or TAR, and there was confusion among staff regarding what information was sent to and received from the dialysis center. The Director of Nursing and other staff indicated that the facility's policy and physician's orders should be followed, but the required aftercare instructions and consistent communication with the dialysis center were lacking. The dialysis center also reported not receiving the expected documentation from the facility, and there was no communication binder in place for the resident.
Medication Administration Error: Wrong Laxative Given
Penalty
Summary
A deficiency occurred when a registered nurse administered the wrong medication to a resident during the morning medication pass. Specifically, the nurse gave Senna-Plus, which contains both sennosides and docusate sodium, instead of the prescribed Senna 8.6 mg, as documented in the resident's Medication Administration Record (MAR) for constipation. The facility's policy requires medications to be administered according to prescriber orders and for staff to verify the correct medication, dosage, and resident before administration. The error was observed by a surveyor and later confirmed through record review and staff interview, with the Director of Nursing acknowledging that medications should be given as ordered.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in the inappropriate use of antibiotics for three residents. For one resident with a history of abdominal wall abscess, anemia, endometrial cancer, MRSA infection, and fibromyalgia, the medical record showed that the resident did not meet McGeer's criteria for a urinary tract infection (UTI) based on culture results, yet antibiotic therapy was administered. The physician was not notified that the criteria for infection were not met. Similarly, another resident with a duodenal malignancy, bacterial infection, and a stage 2 sacral pressure ulcer received antibiotics for a skin and soft tissue infection (SSTI) despite only meeting two of the four required new or increasing signs or symptoms per McGeer's criteria. This resident was also omitted from the infection line list, and the physician was not updated regarding the lack of infection criteria. A third resident, with diagnoses including head injury, COPD, and atherosclerotic heart disease, was prescribed antibiotics for a respiratory tract infection (RTI) without documentation of any signs or symptoms meeting McGeer's criteria. The infection documentation only noted a sinus infection without further detail, and the physician was not informed that the resident did not meet the criteria for infection. In all three cases, the facility did not follow its own policy requiring communication of lab results and clinical status to the prescriber to determine the appropriateness of antibiotic therapy.
Failure to Update Care Plans for Hoyer Sling Use
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, specifically regarding the practice of leaving Hoyer slings underneath them while seated in Geri chairs and wheelchairs. The facility's policy, dated July 2017, mandates the removal of slings after using a mechanical lift, but this was not adhered to for residents R11, R5, and R3. The surveyor's observations and staff interviews confirmed that the slings were routinely left under residents, contrary to the facility's policy. Resident R11, who has Alzheimer's disease, a history of amputation, and is at high risk for skin breakdown, was observed with a Hoyer sling left under them in a Geri chair. Despite having a care plan for skin integrity issues, the care plan did not include interventions related to the sling. Similarly, Resident R5, who is severely cognitively impaired and at moderate risk for skin breakdown, was observed with a sling left under them in a recliner. R5's care plan also lacked updates regarding the sling. Both residents reported no discomfort from the sling, but the practice was inconsistent with the facility's policy. Resident R3, who is not cognitively impaired and has a history of hemiplegia and diabetes, was observed with a sling left under them after being transferred to a recliner. R3's care plan did include an intervention to leave the sling underneath, but R3 reported discomfort and requested a blanket for additional comfort. Interviews with CNAs and the Director of Nursing revealed that the practice of leaving slings under residents was common, despite the facility's policy requiring their removal. The Nursing Home Administrator mentioned a recent inservice suggesting the practice was acceptable, but no supporting documentation was provided.
Inadequate Use of Assistive Devices Leads to Resident Left Hanging in Lift
Penalty
Summary
The facility failed to ensure the adequate use of assistive devices to prevent injury for a resident, identified as R3, who experienced issues with the lift battery dying mid-transfer. R3, who was not cognitively impaired and required assistance due to conditions such as hemiplegia, hemiparesis, and an acquired absence of the right leg, reported being left hanging in the lift while staff replaced the battery. This situation occurred because the lift battery often died during transfers, and staff had to leave the room to retrieve a new battery. R3 had communicated with maintenance staff about the battery issues, and the facility had ordered new batteries. Interviews with staff revealed that the lift battery dying mid-transfer was a known issue, and staff did not consistently check the battery life before use. The Maintenance Director and Nursing Home Administrator confirmed that new batteries had been ordered and that there were chargers and extra batteries available, although only one battery was observed in the charger during the survey. The Nursing Home Administrator stated that staff should use the manual release to lower residents if a battery dies mid-transfer, but this procedure was not followed, resulting in the resident being left suspended in the lift.
Improper Catheter Bag Placement for Two Residents
Penalty
Summary
The facility failed to provide appropriate care and services for two residents with indwelling catheters, as observed by surveyors. On the specified date, the catheter drainage bags of two residents were found in contact with the floor, contrary to the facility's urinary catheter policy, which aims to prevent urinary-associated complications, including infections. The first resident, who had a history of fractures and hypertension and moderate cognitive impairment, was observed with their catheter bag on the floor due to the bed being in the lowest position. A Certified Nursing Assistant confirmed the improper placement of the catheter bag. The second resident, with a history of hemiplegia, hemiparesis, anemia, and gross hematuria, and severely impaired cognition, was observed with their catheter bag dragging on the floor while attached to their wheelchair. A Licensed Practical Nurse verified the improper placement and adjusted the bag. The Director of Nursing also confirmed that catheter bags should not touch the floor, indicating a lapse in adherence to the facility's infection control procedures.
Inconsistent Adherence to Prescribed Diet for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a prescribed diet was consistently followed for a resident with type 2 diabetes, who was on a consistent carbohydrate hydro-oligomeric (CCHO) diet. During a survey, it was observed that the resident received a full piece of cake instead of the prescribed half piece, as indicated on their meal ticket. The resident accepted the larger portion, stating they were okay with it for that day. The dietary staff, including a cook and a dietary aide, acknowledged the discrepancy and mentioned that they often provided residents with their preferred portion sizes, even if it deviated from the prescribed diet. The dietary manager confirmed that the resident should have received a half piece of cake according to their CCHO diet. However, the facility lacked a policy regarding adherence to prescribed diets, relying instead on staff to follow diet cards. This lack of a formal policy contributed to the inconsistency in following the resident's dietary requirements, as staff prioritized resident preferences over the prescribed diet orders.
Infection Control Deficiency Due to Lack of PPE and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of staff during the care of a resident on Enhanced Barrier Precautions (EBP). On January 9, 2025, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided wound care and assisted with the transfer of a resident without wearing the required personal protective equipment (PPE). The resident, who had multiple diagnoses including severe sepsis, open wounds, and a history of stem cell and bone marrow transplants, was on EBP due to the risk of infection. Despite the presence of an EBP sign on the resident's door, the LPN and CNA did not adhere to the facility's policy requiring PPE during high-contact care activities. Additionally, the facility's policy on cleaning and disinfection of resident-care items was not followed. After assisting the resident, the CNA exited the room with a vital signs machine and placed it in the hallway without disinfecting it, contrary to the facility's policy that requires reusable items to be cleaned and disinfected between residents. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that staff should have worn PPE during high-contact care and that durable medical equipment should be sanitized between each resident use.
Failure to Timely Report and Investigate Resident Altercation
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving two residents. The incident involved a resident with intact cognition and another resident with severe cognitive impairment. The altercation occurred when one resident reportedly yelled and rammed their wheelchair into the other resident in the activity room. Although staff were aware of the incident, it was not reported to the administration in a timely manner, leading to a delay in reporting the incident to the State Agency beyond the required 24-hour timeframe. The facility's investigation revealed that staff were aware of the incident on a Friday evening, but the administration was not informed until the following Monday. The investigation could not determine which staff member intervened during the incident. Additionally, there was no proof of education for certain staff members who were on duty during the incident, indicating a lapse in ensuring all staff were trained on reporting requirements. This deficiency highlights a failure in internal reporting processes and staff education regarding abuse allegations.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. During an initial kitchen tour, the surveyor and the Dietary Manager (DM) observed three outside refuse dumpsters with open lids and garbage on the ground. Specifically, a bag of garbage was found behind the middle dumpster, and scattered pieces of paper were observed around all three dumpsters. The DM indicated that the lids were likely open for ease of use but acknowledged they should be shut to prevent rodents. The DM identified the garbage as belonging to Certified Nursing Staff (CNA) but did not take immediate action to remove it.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not allowing six residents to make choices regarding their meals. For instance, Resident 1, who had moderate cognitive impairment and specific dietary needs, was not asked what they wanted to eat and was given an inadequate protein equivalent. The meal provided did not match the dietary instructions on the meal ticket, and the resident expressed that staff did not ask them about their meal preferences. Resident 4, who had a pureed diet and was non-verbal, was not offered the double portions of entrees as indicated in their plan of care. Instead, they received items not listed on the menu or meal ticket, and staff did not verify if the resident's daughter could make dietary choices on their behalf. Similarly, Resident 10, who also had a pureed diet, did not receive the double portions or the correct items listed on their meal ticket. Staff assumed the resident's preferences without asking. Other residents, including Residents 25, 27, and 39, also did not receive meals according to their dietary plans and preferences. Staff made assumptions about their meal choices without consulting them or their activated power of attorney for healthcare. The facility's dietary manager admitted that they did not consider asking residents about their meal preferences, and the regional manager acknowledged that residents' choices were not being honored. The facility planned to implement a new system to address this issue, but at the time of the survey, the deficiency was evident.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide timely written notifications of transfer to three residents (R204, R36, and R19) and did not notify the State Long-Term Care Ombudsman of these transfers. Specifically, R204 was transferred to the hospital due to low blood sugar levels, R36 was transferred twice due to acute kidney injury and low blood pressure with associated symptoms, and R19 was transferred twice due to right-sided weakness and a fall with a head injury. In each case, the medical records did not indicate that the residents received written transfer notices or that the Ombudsman was notified of the transfers. The Assistant Nursing Home Administrator confirmed that written transfer notices were not provided to the residents, and the facility's records showed that the Ombudsman was not notified of the transfers. The Nursing Home Administrator indicated that nurses are expected to use the facility's transfer form when a resident is transferred to the hospital, but this procedure was not followed. The facility's documentation policy, revised in December 2016, requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving healthcare provider, including providing appropriate notices to the resident and/or legal representative.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility did not ensure that three residents received written information regarding the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility when they were transferred to the hospital. Resident 204 was transferred to the hospital due to a low blood glucose reading and did not receive a copy of the bed hold policy. This was confirmed by the Assistant Nursing Home Administrator. Similarly, Resident 36 was transferred to the hospital twice, once for acute kidney injury and once for low blood pressure, headache, and dizziness, but did not receive the bed hold policy on either occasion. The Assistant Nursing Home Administrator confirmed that the bed hold policy was not provided for these transfers, despite a nursing note being completed. Resident 19 was transferred to the hospital twice, once due to right-sided weakness and once due to a fall with a head injury, and did not receive a copy of the bed hold policy on either occasion. The Assistant Nursing Home Administrator confirmed that the bed hold policy was not provided for these transfers. The Nursing Home Administrator indicated that it is expected for nurses to provide a copy of the facility's bed hold policy and transfer form when a resident is transferred to the hospital. However, this expectation was not met in these cases, leading to the deficiency.
Failure to Ensure Resident Safety and Proper Fall Management
Penalty
Summary
The facility did not ensure each resident received adequate supervision and assistive devices, did not complete fall assessments, and did not implement interventions to prevent falls for two residents. On one occasion, staff used a lift with defective brakes and a defective sling to transfer a resident. Despite repeated warnings from a CNA about the broken sling, it continued to be used. Additionally, the lift with broken brakes was used because the other lift was in use, and management was not aware of the issue until the surveyor's observation. Another resident experienced a fall with a head injury, and the facility failed to appropriately assess the resident following the fall. The resident's care plan was not updated with new interventions to prevent future falls. Despite the IDT's review, the care plan remained unchanged, and the interventions were not accessible to CNAs. Neurochecks were not completed as required, and the documentation was inconsistent with the facility's policies. The facility's policies on safety, supervision, and fall risk management were not followed. The use of defective equipment and the lack of proper assessment and documentation contributed to the deficiencies. The facility's failure to update care plans and ensure staff access to new interventions further exacerbated the issue, leading to inadequate care and supervision for the residents involved.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility did not ensure that a resident received the necessary care and services for respiratory therapy. The resident was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not included in the care plan for assessment, evaluation, or monitoring. The facility's CPAP Therapy policy requires a physician's order and documentation of various aspects of the therapy, which were not followed in this case. Additionally, the facility's Respiratory Therapy-Prevention of Infection policy outlines specific procedures for preventing infection, which were also not adhered to, as evidenced by the lack of labeling on the CPAP machine's tubing to indicate when it was last changed. The resident, who had diagnoses including obstructive sleep apnea, dementia, weakness, and anxiety, was observed with a CPAP machine on the bedside table. The resident indicated that not all staff were educated on the CPAP mask/machine, leading to inconsistent use. The Director of Nursing confirmed that the resident did not have a physician's order for CPAP therapy and that the care plan did not address the use of CPAP therapy or the cleaning schedule for the equipment. The tubing on the CPAP machine was also not labeled with a date/time, which is necessary for infection prevention.
Failure to Monitor High-Risk Medication
Penalty
Summary
The facility did not ensure proper monitoring of a high-risk medication for one resident diagnosed with diabetes mellitus. The resident had physician orders for both short-acting and long-acting insulin to manage high blood sugar levels. However, the resident's plan of care lacked interventions to monitor for signs and symptoms of hypoglycemia and hyperglycemia. This deficiency was identified during a review of the resident's medical record and confirmed through an interview with the Director of Nursing (DON). The resident's medical record included specific orders for Humalog and Lantus insulin, with detailed instructions on dosage and administration. Despite these orders, the resident's baseline care plan did not address the need to monitor for potential complications related to blood sugar levels. The DON acknowledged that the comprehensive care plan was incomplete and that the baseline care plan did not include necessary monitoring interventions for hypoglycemia and hyperglycemia.
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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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