Rolling Hills Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparta, Wisconsin.
- Location
- 14400 Cty Hwy B, Sparta, Wisconsin 54656
- CMS Provider Number
- 525430
- Inspections on file
- 15
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rolling Hills Rehab Ctr during CMS and state inspections, most recent first.
The facility failed to report an alleged abuse incident to the State Agency within the required 2-hour timeframe. A resident with dementia and severe cognitive impairment was pinched on the arm by another cognitively impaired resident. Nursing documentation showed that leadership was informed mid-afternoon, but the formal abuse report to the State Agency was not submitted until that evening. Interviews with an RN, the DON, and the Administrator confirmed awareness of the 2-hour reporting requirement for abuse allegations and that the report was sent later than required by facility policy and regulation.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in linen handling, PPE use, and hand hygiene. Clean linens were transported uncovered, PPE was improperly removed outside a resident's room, and an LPN did not perform hand hygiene or cleanse an injection site before administering insulin. The Nursing Home Administrator and Director of Nursing acknowledged these lapses.
The facility failed to provide consistent restorative services to maintain or improve ROM and mobility for four residents, as outlined in their care plans. Residents with conditions such as arthritis, muscular dystrophy, osteoarthritis, and Parkinson's disease did not receive the prescribed frequency of exercises, leading to potential declines in their functional abilities. Staffing issues and the absence of a Restorative Services Policy contributed to these deficiencies.
The facility failed to protect two residents from abuse. One resident with Alzheimer's was verbally abused by a CNA who threatened to carry them out of the room. Another resident was physically assaulted by a fellow resident during an altercation. Despite reports and staff intervention, the facility did not follow its abuse prevention policy, leaving residents unprotected.
The facility failed to report two incidents of potential misconduct to the state agency. In one case, a CNA threatened a resident with severe cognitive impairment, and in another, a resident-to-resident altercation occurred. The facility did not follow its policy for reporting such incidents, and the administration was unaware of some events due to a breakdown in the reporting process.
A facility failed to investigate allegations of abuse and protect residents during the investigation. A CNA accused of verbal abuse continued working with a resident with severe cognitive impairment. Additionally, a resident with aggressive behavior was involved in multiple altercations without thorough investigations or identification of affected residents. Staff interviews revealed a lack of awareness and communication regarding these incidents.
The facility failed to transmit MDS assessments within the required timeframe for three residents, resulting in a deficiency. The assessments for these residents, who were either self-pay or on a Medicare Advantage Plan, were completed but not transmitted to CMS. The issue was identified through record reviews and interviews, with the facility's staff citing payor source as the reason for non-transmission.
A facility failed to ensure a safe environment and adequate supervision for two residents. One resident with cerebral palsy was left unattended while connected to a mechanical lift, and another resident with severe cognitive impairment exhibited aggressive behavior without increased supervision. Despite multiple incidents, no new interventions were documented, and staff acknowledged the inability to provide consistent 1:1 supervision due to staffing limitations.
The facility exceeded the acceptable medication error rate, with surveyors observing 4 errors out of 35 opportunities, resulting in an 11.4% error rate. Two residents received insulin injections from pens that were not primed, contrary to the manufacturer's instructions and facility procedures. The LPNs involved failed to follow proper priming protocols, and one insulin pen lacked an open date or expiration date label. The DON acknowledged previous training on insulin pen usage and expected staff to prime pens before use.
The facility failed to properly label and store insulin pens, affecting two residents. An insulin pen was found without an opened date and not refrigerated, while another was administered without proper labeling. Staff admitted to not following protocol, potentially impacting medication effectiveness.
A facility failed to thoroughly investigate a resident-to-resident altercation involving a cognitively impaired resident who became upset and squeezed another resident's hand. The facility did not interview witnesses, provide increased supervision for the involved resident, or educate staff following the incident, as required by their policy.
A resident with severe cognitive impairment left the facility without staff knowledge and was not added to the Wanderer's List for increased supervision, contrary to facility policy. The resident's care plan lacked interventions for wandering risk, and no prior risk assessment was noted. The IDT determined the resident was not at risk for future wandering, but the facility later acknowledged the resident should have been added to the list.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident to the State Agency (SA) as required by regulation and its own policy. The facility’s “Misconduct Investigation and Reporting” policy required staff to immediately report incidents to a nurse or supervisor, for the nurse/supervisor to immediately notify the Administrator after ensuring resident safety, and for any allegation involving abuse or resulting in serious bodily injury to be reported within two hours of discovery. Resident 2, who had dementia, anxiety disorder, and severe cognitive impairment (BIMS score of 3/15) and was mobile with a walker, was involved in an incident in which another resident pinched their arm. Nursing documentation for Resident 2 on the date of the incident showed that the DON and social worker were updated at 3:00 PM, and the care plan was revised the same day to keep Resident 2 an arm’s length away from Resident 1. Resident 1 had cerebral palsy, seizures, and moderate cognitive impairment with short- and long-term memory loss. The facility’s Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report showed the report was submitted to the SA at 8:50 PM on the date of the incident. During interview, RN1 stated she became aware of the pinching incident sometime after breakfast and reported it to management but could not recall the exact time. The DON stated that such incidents are typically reported within two hours and that the Administrator manages reporting to the SA. The Administrator stated that incidents with injuries or serious injuries must be reported to the state within two hours and characterized this incident as not involving serious injuries but still subject to the two-hour reporting requirement. The Administrator confirmed the initial report to the SA was made at 8:50 PM and acknowledged, after reviewing the facility policy, that the incident should have been reported within two hours.
Infection Control Deficiencies in Linen Handling, PPE Use, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed by surveyors. One issue involved the improper handling of clean linens. A Nursing Support Aide was observed transporting clean linens in the hallway without using a covered cart, which is against federal regulations that require linens to be handled in a manner that prevents the spread of infection. The Nursing Home Administrator acknowledged the oversight, noting that the change in linen handling practices might have contributed to the lapse. Another deficiency was noted in the use of Enhanced Barrier Precautions (EBP) for a resident. A Certified Nursing Assistant was observed donning personal protective equipment (PPE) before entering a resident's room but removing it outside the room, contrary to the facility's policy and CDC guidelines, which require PPE to be removed inside the room to prevent contamination. The Director of Nursing admitted that the current practice did not align with the facility's policy and acknowledged the potential risk of infection transmission. Additionally, poor hand hygiene practices were observed during medication administration. A Licensed Practical Nurse failed to perform hand hygiene before and after gloving and did not cleanse the injection site with an alcohol pad before administering insulin to a resident. The nurse admitted to the oversight, citing nervousness as a reason for the lapse. The Director of Nursing was aware of these deficiencies and expected staff to adhere to infection control procedures.
Inadequate Restorative Services for Residents
Penalty
Summary
The facility failed to provide appropriate restorative services to maintain or improve the range of motion (ROM) and mobility for four residents, as required by their care plans. Resident 25, who was diagnosed with arthritis, was supposed to receive restorative services at least three times per week but only participated in the program on a limited number of days over several months. During the survey period, the resident was not observed participating in any restorative services, and she reported inconsistencies in receiving the exercises from the Restorative Aide. Resident 26, diagnosed with muscular dystrophy, had a care plan that lacked specific frequency and duration for restorative services. The resident participated in the program sporadically, and during the survey period, was not observed receiving any restorative services. The resident expressed a desire for more frequent exercises to maintain his abilities and had previously communicated this to the nursing staff without any changes being made. Residents 30 and 31 also experienced deficiencies in their restorative care. Resident 30, with a history of osteoarthritis and blood clots, was supposed to receive daily exercises but participated infrequently. Resident 31, diagnosed with Parkinson's disease, was to receive services five times per week but similarly had limited participation. The facility's Director of Nursing confirmed the lack of a Restorative Services Policy and acknowledged staffing issues, including the part-time schedule of the Restorative Aide, which contributed to the inconsistency in providing the necessary services.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by the actions of a Certified Nursing Assistant (CNA) and an altercation between residents. One resident, who was admitted with Alzheimer's dementia and severe impaired cognition, was verbally abused by a CNA. The CNA threatened to physically carry the resident out of the room if they did not comply with the CNA's demands. This incident was reported by another resident with intact cognition, who witnessed the CNA's behavior and reported it to another staff member. Despite the report, the facility did not take adequate steps to protect the resident from further verbal abuse. In another incident, a resident was not protected from physical abuse during an altercation with another resident. The aggressor grabbed the victim's walker and physically assaulted them by swinging and hitting them. Although staff intervened, the victim expressed fear and chose to stay in their room to avoid further interactions. The Director of Nursing and the Nursing Home Administrator acknowledged that the facility's policy for preventing abuse was not followed, resulting in the residents not being adequately protected from abuse.
Failure to Report Abuse and Resident Altercations
Penalty
Summary
The facility failed to report two incidents of potential misconduct to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incidents. The first incident involved a Certified Nursing Assistant (CNA) who threatened a resident with severe cognitive impairment by stating that the CNA would throw the resident over her shoulder if the resident did not comply with her instructions. This incident was reported by another resident with intact cognition, who witnessed the event and expressed fear for the threatened resident. Despite the seriousness of the threat, the facility did not report the incident to the state agency, and the CNA continued to provide care to the resident involved. The second incident involved a resident-to-resident altercation where one resident grabbed another resident's walker and swung at them, hitting and grabbing their wrist. The facility's nursing progress notes documented the altercation, but there was no evidence that the incident was reported to the state agency or that a supervisor was notified. Interviews with staff revealed a lack of clarity on the reporting process for such incidents, with some staff indicating they would only report severe incidents to a supervisor. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unaware of some of the incidents due to a failure in the reporting process. The facility's policy required immediate reporting of such incidents to the administration and the state agency, but this was not followed. The NHA admitted to not considering the incidents as abuse concerns and was unaware that the CNA continued to work with the resident involved in the first incident. The lack of reporting and failure to follow facility policy contributed to the deficiency identified by the surveyors.
Failure to Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse were thoroughly investigated and that residents were protected during the investigation process. Specifically, a Certified Nursing Assistant (CNA) was accused of verbally abusing a resident with severe cognitive impairment, yet the CNA continued to work with the resident during the investigation. The facility's policy required immediate action to protect residents from potential abuse, but this was not followed, as evidenced by the CNA's continued interaction with the resident and the lack of a clear investigation completion date. Additionally, the facility did not conduct thorough investigations into multiple incidents involving a resident with a history of aggressive behavior. This resident, who had severe cognitive impairment, was involved in several altercations with other residents, yet there was no documentation of a proper investigation or identification of affected residents. The facility's policy required staff to report such incidents and conduct thorough investigations, but this was not done, leading to a lack of preventative measures to avoid further incidents. Interviews with staff revealed a lack of awareness and communication regarding the incidents and the necessary steps to address them. The Director of Nursing and Social Worker were unaware of some incidents, and the Nursing Home Administrator did not consider certain incidents as abuse concerns. This lack of communication and adherence to policy contributed to the failure to protect residents and thoroughly investigate allegations of abuse.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments within the required 14 days of completion for three residents, resulting in a deficiency. Resident 40 had two quarterly MDS assessments completed on 10/02/24 and 12/31/24, neither of which were transmitted to the Centers for Medicare & Medicaid Services (CMS) by the survey's end on 02/20/25. Similarly, Resident 47 had a Prospective Payment System (PPS) discharge assessment completed on 11/08/24 and a quarterly MDS completed on 12/23/24, both of which were not transmitted. Resident 31 also had two quarterly MDS assessments completed on 10/02/24 and 12/31/24 that were not submitted. These assessments were marked as completed but were not transmitted or accepted by CMS. The deficiency was identified through record reviews and interviews conducted by the surveyor. During the interview, the Medical Records staff member stated that the MDS assessments were not transmitted because the residents were either self-pay or on a Medicare Advantage Plan. The Nursing Home Administrator confirmed that the non-transmission was due to the payor source. The surveyor advised the administrator to refer to the Resident Assessment Instrument manual and F640 regulation, highlighting the requirement to transmit MDS data regardless of the payor source.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. Resident R13, who has spastic quadriplegic cerebral palsy and muscle weakness, was left unattended while connected to mechanical lift equipment. The surveyor observed R13 in his room, seated in a broda chair with a mechanical lift sling positioned under him and attached to the lift, without any staff present. This situation persisted for six minutes until a Certified Nursing Assistant (CNA) returned with another CNA to assist with the transfer. The Director of Nursing (DON) expressed concern over this practice, acknowledging that it could have resulted in harm from entrapment. Resident R35, who has severe cognitive impairment and a history of aggressive behavior, did not receive increased supervision to prevent resident-to-resident altercations. Despite multiple incidents of aggression and altercations with other residents, there was no documentation of new interventions or increased supervision being implemented. The incidents included R35 yelling and kicking a table, attempting to hit another resident, and grabbing another resident's walker. Interviews with staff revealed that while they attempted to monitor R35, they were often unable to provide consistent supervision due to other responsibilities. The facility's failure to implement adequate supervision and interventions for R35's aggressive behavior was acknowledged by the DON, who admitted that 1:1 supervision was not feasible due to staffing limitations. This lack of supervision and intervention left other residents vulnerable to potential harm from R35's actions. The surveyor's review of documentation confirmed that no new measures were put in place to address the ongoing safety concerns related to R35's behavior.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as surveyors observed 4 errors out of 35 medication opportunities, resulting in an error rate of 11.4%. This deficiency affected two residents during the medication administration process. One resident, who was admitted with a diagnosis of type 2 diabetes mellitus, received two insulin injections using pens that were not primed before administration. The Licensed Practical Nurse (LPN) responsible for administering the insulin did not follow the manufacturer's instructions or the facility's procedure for priming the insulin pens, leading to the improper administration of insulin. Another resident also received insulin from a pen that was not primed before administration. The LPN administering the insulin failed to prime the Humalog insulin pen with 2 units before preparing the prescribed dose. Additionally, the surveyor noted that the Humalog pen used did not have an open date or expiration date label. The Director of Nursing (DON) acknowledged that there had been previous training on insulin pen usage and expressed an expectation that staff should prime the pens before use, indicating a lapse in adherence to proper procedures by the nursing staff.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling and storage of insulin pens, which is a violation of accepted professional practices. During a medication storage tour, a surveyor observed an insulin pen for a resident with type 2 diabetes mellitus that was not labeled with an opened date and was not refrigerated. The insulin pen, Tresiba FlexTouch, was found in the medication cart drawer without the required labeling, which is necessary to track its usage within the 28-day period after opening. The registered nurse responsible for the medication admitted to forgetting to date the pen when it was initially opened, acknowledging the requirement for labeling. In another instance, a surveyor observed an LPN administering a Humalog insulin pen to a resident without an open date or expiration date label. When questioned, the LPN was unsure of the correct procedure and admitted that the insulin should have been discarded and replaced with a new one. This lack of proper labeling and adherence to protocol for insulin administration could potentially affect the effectiveness of the medication for the residents involved.
Failure to Investigate Resident Altercation and Implement Protective Measures
Penalty
Summary
The facility failed to conduct a thorough investigation of a resident-to-resident altercation, as required by their policy. The incident involved a resident with a diagnosis of cerebral vascular accident and aphasia, who has a moderate cognitive impairment. This resident became upset after being unable to locate the TV remote and subsequently threw items off a dining table and squeezed another resident's hand. The facility's policy mandates that all resident witnesses or victims should be interviewed as part of the investigation, but this was not done. Additionally, the facility did not provide evidence of increased supervision for the involved resident for 48 hours following the incident, as per their report. There was also a lack of staff education following the incident to prevent further potential abuse. The Nursing Home Administrator confirmed that interviews with resident witnesses did not occur, and there was no documentation of increased supervision or staff education, indicating a failure to implement necessary interventions to protect residents during the investigation process.
Inadequate Supervision for Resident Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision to reduce the risk of wandering or elopement for a resident who left the facility without staff's knowledge. The resident, who had severe cognitive impairment and was admitted with diagnoses including hemiplegia and aphasia, was not added to the facility's Wanderer's List for increased supervision after the incident, as required by the facility's policy. The resident's care plan did not include interventions for wandering or elopement risk, and no risk assessment for wandering or elopement was noted in the medical record prior to the incident. The facility's Interdisciplinary Team (IDT) reviewed the incident and determined that the resident was upset about a chair being moved, which led to the elopement. Despite this, the IDT decided not to add the resident to the Wanderer's List or implement additional safety measures like a Wanderguard, as they assessed the resident not to be at risk for future wandering. The Director of Nursing and Nursing Home Administrator acknowledged that the resident should have been added to the Wanderer's List after the incident, recognizing a lapse in following the facility's policy.
Latest citations in Wisconsin
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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