Stevens Point Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Stevens Point, Wisconsin.
- Location
- 1800 Sherman Ave, Stevens Point, Wisconsin 54481
- CMS Provider Number
- 525353
- Inspections on file
- 29
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Stevens Point Health Services during CMS and state inspections, most recent first.
The facility did not notify the State Long-Term Care Ombudsman of multiple resident transfers and discharges as required by policy. Several residents with varying medical conditions and cognitive statuses were either transferred to the hospital or discharged home, but the Ombudsman was not informed in any of these cases.
Two residents, one with impaired cognition and another who was cognitively intact, were prescribed multiple medications, including psychotropic and anticonvulsant drugs, without the facility obtaining the required written consents. In one case, only verbal consent was documented from a POAHC, and in the other, no medication consents were obtained, as confirmed by the NHA.
A resident with multiple medical conditions was prescribed sertraline and trazodone, but staff failed to document monitoring for the efficacy or adverse consequences of these psychotropic medications as required by facility policy. The absence of such monitoring was confirmed through record review and staff interview, with the DON acknowledging the oversight.
A facility did not ensure a timely and complete background check for an agency RN, allowing the nurse to begin work before a properly dated Background Information Disclosure (BID) form was on file. The missing date on the BID form was not identified or addressed by the Business Office Manager, and the agency only provided a correctly dated form after the RN had already started.
A resident with multiple complex medical conditions was readmitted to the facility twice after hospitalizations for sepsis and urosepsis, but the care plan was not revised to address these significant changes in condition. Previous interventions for monitoring infection and catheter care had been resolved and were not reinstated, leaving the care plan outdated and not reflective of the resident's current needs.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A resident with diabetes and heart failure was given 81 mg EC aspirin and two sprays of fluticasone propionate nasal spray in each nostril, contrary to physician orders for aspirin in capsule form and only one spray per nostril. The RN administering the medications was unsure about the transcription of the aspirin order, and the DON confirmed both the transcription and administration errors.
A resident with multiple chronic conditions and MRSA colonization was care planned for enhanced barrier precautions (EBP), requiring staff to use gowns and gloves during high-contact care. A CNA was observed providing peri-care without a gown, despite posted EBP signage and care plan instructions. The CNA admitted to not following EBP protocol, and the facility lacked a specific EBP policy when requested.
A medication cart was found unlocked and unattended near the nurses' station, with two residents nearby—one walking past with a walker and another sitting in the common area. Facility policy requires medication carts to be locked when not attended by authorized staff. The RN involved acknowledged leaving the cart unlocked, and the DON confirmed that carts should always be secured.
Surveyors found that staff did not consistently follow individualized meal tickets or accommodate food preferences for multiple residents, resulting in missed or incorrect meal components such as desserts, beverages, and side items. Interviews with staff and management confirmed that meal tickets were not always followed, and supply issues contributed to some omissions. Residents with specific dietary needs, including those with cardiac diets and dysphagia, did not receive meals as ordered.
A resident with diabetes, a recent stroke, and moderate cognitive impairment was transferred using a sit-to-stand lift by two CNAs while wearing non-gripper socks, contrary to facility policy requiring non-skid footwear during transfers. The DON confirmed that proper footwear should have been used to ensure safety.
A resident with severe cognitive impairment and swallowing difficulties was not provided with lidded cups and a divided plate during a meal, despite these items being specified on the meal ticket and required by facility policy. Staff and management confirmed the resident should have received the adaptive equipment.
Staff did not use required PPE, including gowns and gloves, during high-contact care activities for a resident on Enhanced Barrier Precautions (EBP), despite clear policy and signage. The DON confirmed that EBP should have been followed during these cares.
A resident and their family reported concerns of neglect and inappropriate staff behavior, including delayed care and improper transfer methods. Despite these reports, staff did not recognize or report the allegation to the State Agency as required, and the administrator was unaware of the incident until the survey.
A resident with multiple health conditions reported not receiving care for an extended period, resulting in incontinence, and relayed this to a medication technician. The concern was passed to a social worker, but no investigation or documentation followed. Additionally, the resident's family reported staff making inappropriate comments and concerns about transfer equipment, but these were not fully investigated or documented.
A resident admitted with a left heel pressure injury did not receive accurate and comprehensive wound assessments as required by facility policy. Documentation showed inconsistencies in wound staging and tissue description, and the facility lacked wound care certified nurses, relying on an external provider while the resident was followed by an outside wound clinic. These actions resulted in a failure to provide necessary care and services to promote healing and prevent further pressure injury development.
Staff did not adhere to infection control protocols during medication administration, including failing to perform hand hygiene and not wearing required PPE such as gowns and gloves when caring for residents on contact precautions. Both a medication technician and an LPN were observed not following these procedures, and acknowledged their lapses during interviews. Facility policy and posted signage required these infection control measures, but they were not implemented as observed.
A resident with dementia experienced a decline in health, including weight loss and reduced transfer ability, without the facility notifying the court-appointed Guardian. Despite significant changes, the care plan was not updated, and the Guardian was not informed, leading to dissatisfaction when the resident was found unresponsive and transferred to a hospital. The facility acknowledged the communication failure and the need for a therapy consultation.
A resident with dementia experienced significant weight loss due to the facility's failure to consistently monitor and document meal intake. Despite the Registered Dietitian's involvement, 18.36% of meals were undocumented, and the resident's cognitive decline led to increased meal refusals. The Director of Nursing acknowledged the oversight in documentation and review processes.
Two residents in the facility did not receive necessary care to prevent and heal pressure injuries. One resident developed an unstageable deep tissue injury on the heel due to splints not being removed for skin checks, and a sacral pressure injury was not treated promptly. Another resident's heel pressure injury was not assessed or treated in a timely manner, leading to infection. The facility failed to follow its policy requiring weekly assessments, resulting in inadequate documentation and care.
The facility failed to ensure proper PPE usage for two residents on enhanced barrier precautions (EBP). A CNA assisted a resident with urinary concerns without wearing a gown, despite EBP signage and policy requirements. Another CNA provided care to a resident with wounds and colonized bacteria without the necessary gown. Both residents, who were not cognitively impaired, confirmed the inconsistency in PPE usage.
A resident with COPD and diabetes, requiring staff assistance for bathing, did not receive scheduled showers on multiple occasions. The resident, who had moderate cognitive impairment, was scheduled for weekly showers but missed several due to refusals and lack of documentation. The DON confirmed the resident often refused care and that missing documentation indicated missed showers.
A resident with COPD, lung cancer, and bone cancer did not receive timely and accurate administration of oxycodone as per physician orders. The facility's Medication Administration Audit Report showed multiple instances of late administration and improper concurrent dosing of scheduled and PRN oxycodone. The DON confirmed these discrepancies, indicating a failure to adhere to the facility's medication administration policy.
The facility did not designate a qualified person to serve as the food and nutrition services director. The Dietary Manager had not completed an approved certification course and was only enrolled in a ServSafe course. The DM had previous experience in maintenance and as a cook in an assisted living facility. The facility had a contracted dietician who was onsite every other week.
The facility failed to ensure food was stored and prepared safely, with staff not following proper hand hygiene, cleanliness, and equipment storage protocols. Additionally, unit refrigerator and freezer temperature logs were not maintained, and open items were not dated.
The facility did not ensure that the designated Infection Preventionist (IP) completed the required training and was employed at least part-time. The DONM, who was overseeing the IP role, did not work scheduled hours and was more of a consultant. The ADON, who was being mentored, had not completed all required training modules. This had the potential to affect all 42 residents.
A resident with a right femur fracture and moderately impaired cognition experienced significant pain but did not receive timely pain relief due to delays in obtaining morphine from the emergency kit. The facility's reliance on a PIXUS machine and issues with the pharmacy contributed to the delay, resulting in prolonged suffering for the resident.
The facility failed to ensure the privacy of a resident during personal care. A surveyor observed that the window blind in the resident's door was open, allowing an unobstructed view of the resident's nude body from the nurses' station. Staff interviews confirmed that the blind should have been closed to ensure privacy.
The facility failed to provide necessary respiratory care for two residents using oxygen therapy. Both residents lacked physician's orders and care plans for oxygen use, and their oxygen tubing was not properly managed. The Director of Nursing confirmed these deficiencies during the survey.
A resident received COVID-19 and influenza vaccines despite their legal guardian's signed declination. The Director of Nursing confirmed the error, noting that staff failed to review the declination sheets properly.
The facility failed to maintain an effective infection control program, resulting in staff not wearing required PPE, improper hand hygiene, and failure to disinfect equipment during care for two residents. These lapses were confirmed by the DON and involved a CNA and an RN not following established protocols.
The facility failed to ensure that three residents were offered the PCV20 vaccine as per CDC guidelines, despite having received previous pneumococcal vaccinations. The Director of Nursing confirmed that the residents should have been offered the vaccine and that the documentation should have been included in their medical records.
The facility failed to ensure adequate fall prevention for three residents, including not updating care plans after falls, not addressing trip hazards, and not securing smoking materials as required.
The facility did not ensure the QAPI committee met at least quarterly and failed to provide verification of attendance for required members, impacting all 42 residents. Missing and unsigned sign-in sheets were found, and interviews confirmed the lack of proper documentation.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of transfers or discharges for four residents, as required by policy and regulation. Specifically, one resident with multiple medical conditions and intact cognition was transferred to the hospital for evaluation, but the Ombudsman was not notified. Another resident with moderately impaired cognition and an activated Power of Attorney for Healthcare was discharged home, yet the required notification was not made. A third resident, who had intact cognition and multiple chronic conditions, was transferred to the hospital for a change in condition and later returned, but again, no notification was sent. The fourth resident, also with intact cognition and significant medical diagnoses, was transferred to the hospital on three separate occasions for serious health issues, including septic shock and urosepsis, without Ombudsman notification each time. The facility's policy mandates that the Social Services Director or designee must notify the Ombudsman of non-emergency transfers or discharges at least 30 days in advance, and for emergency transfers, provide notice via a monthly list. However, record review and staff interviews revealed that the facility did not report any transfers or discharges to the Ombudsman during the period in question. This deficiency was confirmed when the Nursing Home Administrator acknowledged the lack of reporting and provided documentation showing that no notifications had been made.
Failure to Obtain Written Medication Consents for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, both with significant medical and cognitive conditions, or their legal representatives, were fully informed and provided written consent for prescribed medications, including psychotropic and anticonvulsant drugs. For one resident with moderately impaired cognition and an activated Power of Attorney for Healthcare (POAHC), verbal consent was obtained for medications such as divalproex sodium (Depakote), buspirone, and clindamycin, but there was no documentation of written consent signed by the POAHC. This resident had diagnoses including dementia, stroke, diabetes, seizures, and depression, and was unable to make healthcare decisions independently. Another resident, who was cognitively intact and made their own healthcare decisions, was prescribed multiple medications including quetiapine, hydroxyzine, Ambien, Lyrica, Lexapro, and oxcarbazepine for conditions such as bipolar disorder, depression, anxiety, insomnia, and neuropathic pain. The facility did not obtain any medication consents for these psychotropic medications. The Nursing Home Administrator confirmed that signed medication consents should have been obtained for both residents.
Failure to Monitor Psychotropic Medication Efficacy and Adverse Consequences
Penalty
Summary
A deficiency occurred when the facility failed to monitor for adverse consequences or the effectiveness of psychotropic medications prescribed to a resident. The resident, who had diagnoses including urinary tract infection, chronic respiratory failure, COPD, encephalopathy, anxiety, and insomnia, was prescribed sertraline for anxiety and trazodone for sleep. Upon review, the resident's medical record did not contain documentation of monitoring for the efficacy or adverse consequences of either medication, such as sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity, excess weight gain, anxiousness, or sleeplessness. The facility's policy required that each resident's drug regimen be reviewed and monitored for unnecessary drugs, efficacy, and adverse consequences, especially for psychotropic medications. Despite this, there was no evidence in the resident's Medication Administration Record or Treatment Administration Record that such monitoring was performed for the prescribed antidepressants. The deficiency was confirmed through staff interview and record review, with the Director of Nursing acknowledging that monitoring should have been completed.
Failure to Complete Timely Background Check for Agency RN
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse by not ensuring a thorough and timely caregiver background check for one agency registered nurse. Specifically, the Background Information Disclosure (BID) form for the agency RN was not dated, and the nurse began working at the facility before a properly completed BID form was on file. The Business Office Manager did not notice the missing date on the BID form and did not follow up with the agency prior to the nurse's start date. The agency later provided a BID form with an effective date after the nurse had already started working.
Failure to Revise Care Plan After Hospital Readmissions for Sepsis/Urosepsis
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was revised in a timely manner for one resident following two separate hospital readmissions for sepsis and urosepsis. The resident, who had multiple diagnoses including urosepsis, bullous pemphigoid, COPD, various malignancies, UTIs, schizophrenia, and anxiety, was readmitted to the facility after hospitalizations for sepsis/urosepsis related to urinary tract infections. Despite these significant changes in the resident's condition, the care plan was not updated to reflect the new diagnoses or to include appropriate monitoring and interventions for infection. Record review and staff interviews revealed that the care plan previously included interventions for monitoring signs and symptoms of UTI, but these interventions had been resolved prior to the resident's hospitalizations and were not reinstated upon readmission. The care plan also referenced a catheter, but all related interventions had been resolved months before the most recent hospitalizations. As a result, the care plan did not address the resident's current needs following the episodes of sepsis and urosepsis.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Order Transcription and Administration Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes and heart failure was administered medications that did not match the physician's orders. The resident, who was cognitively intact according to a recent assessment, was observed receiving 81 mg of enteric coated (EC) aspirin and two sprays of fluticasone propionate nasal spray in each nostril. However, the physician's orders specified aspirin 81 mg in capsule form (which was incorrectly transcribed from the hospital discharge summary that indicated EC tablet) and only one spray of fluticasone propionate in each nostril. The registered nurse administering the medications was unsure why the aspirin order was transcribed as a capsule and acknowledged that the facility did not have aspirin in capsule form. Upon review, it was confirmed that the order was incorrectly transcribed and the medication was not administered as ordered. Additionally, the nurse confirmed that the resident received double the prescribed dose of fluticasone propionate. The Director of Nursing verified these discrepancies and confirmed that the medications were not administered according to the physician's orders.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to maintain an infection prevention and control program as required for a resident on enhanced barrier precautions (EBP). The resident, who had multiple diagnoses including type 2 diabetes, chronic ulcers, MRSA colonization, and chronic respiratory failure, was care planned for EBP due to colonization with a multidrug-resistant organism (MDRO). The care plan and Kardex specified that staff should use gowns and gloves during high-contact care activities, such as peri-care and toileting, to prevent the transmission of infection. On the day of the survey, a certified nursing assistant (CNA) was observed providing peri-care to the resident without wearing a gown, despite signage indicating EBP and the care plan's requirements. The CNA acknowledged not donning a gown at the start of care and only halted care upon noticing the surveyor. Interviews with the infection preventionist confirmed that staff should follow the resident's precautions and use appropriate personal protective equipment (PPE) during high-contact care. Additionally, the facility did not have a specific EBP policy available when requested, providing only a general transmission-based precautions policy instead.
Unattended and Unlocked Medication Cart Observed
Penalty
Summary
A medication cart was observed unlocked and unattended on the second floor near the nurses' station, with two residents present in the vicinity. One resident walked by the cart using a walker, while another was seated in the common area watching television. The facility's policy requires that medication carts remain locked when not in use or when not attended by authorized personnel, such as licensed nurses or medication aides. The incident occurred when a registered nurse was pulled away from the medication cart and left it unlocked and unattended. Upon interview, the nurse acknowledged that the cart should not have been left in this state. The Director of Nursing also confirmed that medication carts are expected to be locked whenever nurses are not present.
Failure to Follow Individualized Meal Tickets and Food Preferences
Penalty
Summary
Surveyors identified that the facility failed to ensure that food preferences and individualized meal tickets were consistently accommodated for ten out of sixteen sampled residents. Observations, interviews, and record reviews revealed that staff did not follow specific dietary orders and preferences as indicated on residents' meal tickets. For example, one resident on a cardiac diet received a full-size brownie and a white roll instead of the specified half brownie and wheat roll, and another resident with dysphagia did not receive margarine, cabbage, or a frosted brownie as listed on their meal ticket. Additionally, several residents did not receive the beverages indicated on their meal tickets, such as milk, coffee, or juice, during lunch service. Staff interviews confirmed that beverages and other meal components were not always provided as required by the individualized meal tickets. Some staff indicated that residents could have whatever beverages they wanted unless on a fluid restriction, while others acknowledged that the meal tickets should be followed. The Director of Nursing and Dietary Manager both confirmed that staff are expected to follow the meal tickets and provide the items listed, including correct portion sizes and substitutions for allergies or preferences. The Dietary Manager also reported issues with food supply, such as the unavailability of margarine and the substitution of cucumber salad for coleslaw due to a delayed food delivery. Despite these supply issues, the expectation remained that meal tickets should accurately reflect what residents receive and that staff should follow them as written. The failure to provide meals and beverages according to individualized meal tickets resulted in residents not receiving their prescribed diets, preferences, or required nutritional items during meal service.
Failure to Ensure Proper Footwear During Mechanical Lift Transfer
Penalty
Summary
Staff failed to ensure that a resident with diabetes and a history of stroke wore proper footwear during a mechanical lift transfer. The resident, who had moderate cognitive impairment and was at risk for foot injury and falls, was observed being transferred with a sit-to-stand lift by two CNAs while wearing non-gripper socks. After the transfer, staff assisted the resident in putting on shoes and wheelchair pedals. Facility policy required the use of appropriate techniques and devices to ensure resident safety during transfers, including the use of non-skid footwear as outlined in both the facility's Safe Lifting and Movement of Residents policy and external nursing assistant guidelines. The DON confirmed that the resident should have worn shoes or gripper socks during the transfer, in accordance with these policies.
Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
A deficiency occurred when staff failed to provide adaptive eating equipment as required for one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, cerebral ischemia, and dysphagia. The resident's meal ticket specified the need for cups with lids and a divided plate, in accordance with the facility's Assistive Devices policy and the resident's individualized plan of care. During a lunch observation, the resident was not given the specified adaptive equipment. Interviews with the Director of Nursing and the Dietary Manager confirmed that the resident should have received these items, and that procedures were in place for staff to obtain them if not immediately available.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact care activities for a resident with multiple medical conditions, including a prosthetic heart valve, colostomy, stroke, type 2 diabetes, and a history of infectious diseases. The resident's care plan included an intervention for EBP, and signage on the resident's door indicated the need for these precautions. Despite this, during an observed transfer using a sit-to-stand lift, two CNAs did not don the required personal protective equipment (PPE), such as gowns and gloves, while dressing and transferring the resident. Following the transfer, one CNA acknowledged that both staff members should have worn PPE in accordance with EBP requirements. The DON later confirmed that staff are expected to use gowns and gloves for high-contact care with residents on EBP. The deficiency was identified through observation, staff interviews, and record review, demonstrating a failure to implement the infection prevention and control program as outlined in facility policy.
Failure to Timely Report Alleged Abuse/Neglect to State Agency
Penalty
Summary
An allegation of abuse/neglect involving a resident was not reported to the State Agency (SA) in a timely manner as required by the facility's policy. The resident, who was cognitively intact with a BIMS score of 14 and had diagnoses including obesity, muscle weakness, anxiety, and depression, reported to a Medication Technician (MT) that staff failed to provide care over a weekend, resulting in the resident being left incontinent for an extended period. The resident's family member also reported concerns, including inappropriate staff comments and improper use of transfer equipment. Despite these reports, the facility staff did not follow the policy for reporting alleged violations. The MT relayed the concern to the Social Worker (SW), but the SW did not recognize or act on the abuse/neglect allegation, nor did the SW report it to the SA. The Nursing Home Administrator was unaware of the incident until informed by the surveyor, confirming that the required reporting did not occur.
Failure to Investigate Alleged Abuse/Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse/neglect involving one resident. The resident, who was cognitively intact and had diagnoses including obesity, muscle weakness, anxiety, and depression, reported that staff did not provide care over a weekend, resulting in the resident being left incontinent for an extended period. The resident informed a medication technician about the incident, who then relayed the concern to the social worker. However, the social worker did not inquire further about the incident, did not document the conversation, and did not initiate an investigation into the allegation. Additionally, the resident's family member reported concerns about inappropriate staff comments and the use of a mechanical lift for transfers. While the social worker addressed the transfer equipment issue, the comment made by staff was not investigated or documented. The nursing home administrator was unaware of the allegations and confirmed that a thorough investigation should have occurred, as required by the facility's abuse, neglect, and exploitation policy.
Failure to Accurately Assess and Document Pressure Injury Care
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent the development of pressure injuries for a resident admitted with a pressure injury (PI) on the left heel. The facility did not complete accurate and comprehensive assessments of the resident's left heel PI as required by their own policy, which mandates weekly wound assessments and proper documentation of wound characteristics. Medical records showed inconsistencies in the assessment of the wound, including discrepancies in the type of tissue present and changes in the staging of the PI without clear documentation. The resident's PI progressed from a stage 1 to an unstageable wound, with incomplete information regarding the wound's tissue composition. The resident had multiple diagnoses, including diabetes mellitus, chronic kidney disease, and dementia, and was admitted with a left heel PI. The facility lacked wound care certified nurses and relied on an external wound care provider for weekly rounds, but the resident was followed by an outside wound clinic instead. The facility's documentation and assessment practices did not align with their policy or with best practices for pressure injury management, as evidenced by incomplete and inaccurate wound assessments during the resident's stay.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during medication administration for three residents. Specifically, a medication technician and an LPN did not perform appropriate hand hygiene before preparing medications, before entering residents' rooms, after administering medications, or after exiting the rooms. In addition, both staff members did not don required personal protective equipment (PPE), such as gowns, when providing care to residents on contact precautions. The facility's policies and posted signage required hand hygiene and the use of gloves and gowns for all interactions involving residents on contact precautions, but these procedures were not followed. During direct observation, the medication technician did not perform hand hygiene at any point during medication preparation or administration for two residents, including one on contact precautions, and was unaware of the need to wear a gown. The LPN also failed to perform hand hygiene after removing gloves and handling medication equipment, and did not wear a gown when administering insulin to a resident on contact precautions. Both staff members acknowledged their lapses in hand hygiene and PPE use during interviews, and the DON confirmed the facility's expectations for these practices.
Failure to Notify Guardian of Resident's Decline
Penalty
Summary
The facility failed to notify a resident's court-appointed Guardian of significant changes in the resident's condition, which is a violation of their Change in Condition of the Resident policy. The resident, who had unspecified dementia, experienced a decline in transfer ability and eating habits over several months. Despite these changes, the facility did not communicate with the Guardian, who was responsible for the resident's healthcare decisions. The resident was eventually found unresponsive and transferred to a hospital, where the Guardian expressed dissatisfaction with the lack of communication. The resident's medical records showed a significant weight loss over a few months, indicating a decline in health. Staff interviews revealed that the resident's ability to communicate and eat had deteriorated, and the resident required increased assistance for transfers. However, these changes were not reflected in the care plan, and the staff failed to update the Guardian or the resident's primary care provider about the resident's declining condition. The Director of Nursing and other facility leaders acknowledged that the staff should have communicated the resident's decline to the Guardian and considered a therapy consultation. The facility's interdisciplinary team was supposed to review at-risk resident records weekly, but the necessary updates and notifications were not made. The resident was eventually discharged from the hospital with hospice services and passed away shortly after.
Failure to Monitor and Document Nutritional Intake
Penalty
Summary
The facility failed to consistently monitor and document the nutritional intake of a resident, leading to a significant weight loss. The resident, who had been diagnosed with unspecified dementia and had a court-appointed guardian for healthcare decisions, experienced a decline in cognitive function during their stay. The resident's weight decreased from 207.6 pounds to 158 pounds over a period of several months, with the most severe loss occurring in January. Despite the Registered Dietitian being informed and ordering nutritional supplements, the resident's meal intake was not consistently documented, with 18.36% of meals missing documentation. Interviews with staff revealed that the resident, initially having a good appetite, began refusing meals and had difficulty communicating with staff. The Director of Nursing confirmed that meal intake should be documented for every meal and that the Interdisciplinary Team reviews at-risk resident records weekly. However, the missing documentation was not identified or addressed during these reviews, contributing to the deficiency in monitoring the resident's nutritional status effectively.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and heal pressure injuries for two residents. One resident, admitted with fractures and bilateral splints, developed an unstageable deep tissue injury on the right heel due to the splints not being removed for skin checks. Additionally, a pressure injury on the sacrum was not treated until three days after admission, and an air mattress was not ordered until ten days post-admission. The facility's Director of Nursing confirmed that the splints were not removed for skin checks, and there was no policy addressing skin care with medical devices. Another resident was admitted with a pressure injury on the left heel, but a wound assessment and treatment order were delayed until two weeks after admission. The facility failed to complete weekly wound assessments and did not notify the wound clinic when the wound showed signs of infection. The resident's medical record lacked documentation of the pressure injury assessments for several weeks, and the wound clinic noted a copious amount of purulent exudate, indicating an infection that the facility did not report. The facility's policy required weekly assessments for pressure injuries, which were not followed, leading to a lack of documentation and appropriate wound care. Interviews with the Director of Nursing and other staff confirmed the absence of weekly charting and documentation, and the facility's failure to adhere to its wound care policy and standards of practice.
Inadequate PPE Usage for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices related to the use of personal protective equipment (PPE) for two residents on enhanced barrier precautions (EBP). Resident 2 was on EBP due to urinary concerns, and staff did not don the appropriate PPE during high-contact care. On the observed date, a Certified Nursing Assistant (CNA) entered Resident 2's room wearing only a face mask and gloves, omitting the required gown. This was confirmed by a Licensed Practical Nurse (LPN) and the Minimum Data Set Coordinator (MDSC), who both acknowledged the necessity of a gown for such care. Resident 2, who was not cognitively impaired, also confirmed that staff did not consistently wear PPE when providing care or handling the urinal. Similarly, Resident 3 was on EBP due to wounds and colonized bacteria in the urine. A CNA entered Resident 3's room and assisted with care without wearing the required gown, despite the EBP signage on the door. Resident 3, also not cognitively impaired, confirmed the inconsistency in PPE usage by staff during care. Both residents were aware of their precautionary status and the need for PPE, yet staff failed to adhere to the facility's infection prevention and control program, which mandates the use of PPE according to established policy.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance for bathing, resulting in a deficiency. The resident, who had chronic obstructive pulmonary disease and diabetes mellitus, was admitted with moderate cognitive impairment and required staff assistance for bathing. The resident was scheduled to receive a shower once weekly on Wednesdays. However, documentation revealed that the resident did not receive scheduled showers on four occasions. Additionally, the resident refused showers on two other occasions, as noted by both the facility and hospice staff. The Director of Nursing confirmed that blanks in the shower documentation indicated the resident did not receive a shower and acknowledged that the resident often refused care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate and timely administration of medication for a resident with chronic obstructive pulmonary disease, lung cancer, and bone cancer. The resident had physician orders for oxycodone to be administered every four hours for pain, with an additional as-needed dose every six hours, provided it was not given with the scheduled dose. However, the Medication Administration Audit Report revealed multiple instances where the scheduled doses of oxycodone were administered late, ranging from over an hour to nearly three hours past the scheduled time. Additionally, there was an instance where the scheduled dose was administered concurrently with the as-needed dose, contrary to the physician's orders. The Director of Nursing confirmed that the facility's policy required medications to be administered within one hour of their scheduled time and acknowledged the discrepancies in the administration of the resident's medication. The resident, who had a moderate cognitive impairment, did not consistently receive pain medication as ordered, which could have impacted their comfort and pain management. The facility's failure to adhere to the medication administration policy and physician orders resulted in a deficiency in providing pharmaceutical services to meet the resident's needs.
Unqualified Dietary Manager
Penalty
Summary
The facility did not designate a person to serve as the food and nutrition services director who met the required qualifications. The Dietary Manager (DM) had not completed an approved dietary manager or food service manager certification course or other related education. During an interview, the DM indicated that they had just started as a cook at the facility and had previous experience working in maintenance and as a cook in an assisted living facility. The DM was enrolled in a ServSafe course, which is not an approved Dietary Manager certification course, and planned to enroll in a dietary manager course after completing the ServSafe course. The Nursing Home Administrator confirmed these details and stated that the facility had a contracted dietician who was onsite every other week.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a safe and sanitary manner, potentially affecting all 42 residents. Staff failed to complete hand hygiene after washing dishes and before touching ready-to-eat food. Specifically, a cook was observed touching potatoes and buns with the same gloved hand that had touched other surfaces, and a dietary aide used the same disposable gloves worn under green gloves to put away clean dishes. Both staff members were unaware of the proper hand hygiene protocols as per the Wisconsin Food Code and the facility's policies. The facility also failed to maintain cleanliness and proper equipment storage. A cook was observed cutting carrots on a counter that had splatters of blood and meat remnants, and the microwave contained dried food and splatter. Additionally, a large mixer was left uncovered. These observations were confirmed by the Dietary Manager, who acknowledged that the equipment should be cleaned and covered as per the Wisconsin Food Code and the facility's policies. Furthermore, the facility did not maintain unit refrigerator and freezer temperature logs, and open items in the walk-in cooler and dry storage area did not contain open dates. During a kitchen tour, the surveyor found undated bags of cereal, cheese slices, cut onions, and a container of liquid eggs. The Dietary Manager confirmed that these items should have been labeled with open dates, as required by the Wisconsin Food Code and the facility's policies.
Inadequate Infection Preventionist Staffing and Training
Penalty
Summary
The facility did not ensure that the designated Infection Preventionist (IP) completed the required infection prevention and control training and was employed at least part-time in the facility. During the entrance conference, the Nursing Home Administrator (NHA) informed the surveyor that the Director of Nursing Mentor (DONM) was overseeing the IP role and mentoring the Assistant Director of Nursing (ADON), who was not yet certified as an IP. Interviews with the Director of Nursing (DON) and DONM revealed that the DONM did not work any scheduled hours in the facility and was more of a consultant. The ADON confirmed that the DONM was the facility's IP but did not work scheduled hours and was only available to assist as needed. The ADON also provided proof of partial completion of the required IP training modules but had not completed all 23 modules. The NHA stated that they were not aware that the IP needed to work at least part-time at the facility. The DON mentioned that they might have IP certification at home but later confirmed via email that they could not find the certification. This lack of a qualified and adequately trained IP working at least part-time in the facility had the potential to affect all 42 residents residing in the facility.
Delay in Pain Management for Resident
Penalty
Summary
The facility did not ensure effective pain management for a resident (R91) who required such services. On 3/18/24, R91, who had a right femur fracture and moderately impaired cognition, experienced significant pain but did not receive timely pain relief. The facility's policy required prompt pain management, but there was a delay in obtaining morphine from the emergency kit due to issues with the pharmacy and communication with the hospice nurse. Despite multiple attempts by the nursing staff to expedite the process, the first dose of morphine was not administered until 7:58 PM, several hours after the initial prescription was received at 3:02 PM. The delay was exacerbated by the facility's reliance on a PIXUS machine for emergency medications, which required an authorization code from the pharmacy. The nurse on duty, RN-N, documented multiple calls to both the hospice and the pharmacy, trying to obtain the necessary prescription and authorization. The pharmacy's response was slow, and the process was further delayed when the pharmacist went on break. The Director of Nursing (DON) acknowledged ongoing issues with the pharmacy, stating that the process for obtaining controlled substances was problematic and often resulted in delays. During the delay, R91 exhibited signs of severe pain, including yelling out and moaning. The resident's family was present and expressed their distress over the situation. The next shift nurse, RN-O, confirmed that R91 was in visible pain and that the family did not want the resident to suffer. The first dose of morphine was finally administered by RN-O after the medication was retrieved from the PIXUS machine, but this was several hours after the initial need for pain relief was identified, resulting in prolonged suffering for R91.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility did not ensure the right to personal privacy for one resident (R21) during personal care. On 5/6/24, a surveyor observed that the window blind in R21's door was open, allowing an unobstructed view of R21's bed from the nurses' station. During this time, an LPN and a CNA were providing personal care to R21, and R21's nude body with genitals exposed was visible to others in the common area around the nurses' station. Two residents of the opposite gender were present near the nurses' station at the time of the observation. Interviews with staff confirmed that the window blind should have been closed to ensure R21's privacy. The LPN involved stated that they did not notice the window blind was open when they began personal care. Both the Nursing Home Administrator and the Director of Nursing verified that it is the facility's expectation to provide visual privacy for residents during personal care, and that the window blind should have been closed to maintain R21's privacy and dignity.
Deficiency in Respiratory Care for Residents Using Oxygen Therapy
Penalty
Summary
The facility did not provide the necessary respiratory care and services for two residents who were using oxygen therapy. One resident, R8, was using humidified oxygen from a concentrator without a physician's order, and their care plan did not address oxygen use. Additionally, R8's oxygen tubing was not labeled to indicate the date it was last changed. During an interview, R8 could not recall the frequency of tubing changes or when it was last changed. The water reservoir chamber for humidification was found to be empty. The Director of Nursing confirmed that there was no order for humidified oxygen or a care plan for oxygen use for R8, and the facility did not have a policy for labeling oxygen tubing, although it was expected to be changed weekly based on best practice. Another resident, R144, was also using oxygen from a concentrator without a physician's order or a care plan addressing the use of oxygen. R144 had moderately impaired cognition and was unable to provide information about the frequency of tubing changes or the oxygen flow rate. The Director of Nursing confirmed that there were no orders for oxygen use or care and management of the oxygen tubing prior to the surveyor's review. Orders were obtained from R144's physician only after the surveyor's findings.
Vaccines Administered Despite Declination
Penalty
Summary
The facility administered COVID-19 and influenza vaccines to a resident (R11) despite the resident's legal guardian having declined the vaccines. R11 was admitted with multiple diagnoses including chronic obstructive pulmonary disease (COPD), multiple sclerosis, type 2 diabetes with neuropathy, and respiratory syncytial virus (RSV) pneumonia. On 1/3/24, R11's legal guardian signed a declination form for both vaccines, but later that same day, the vaccines were administered to R11. This was confirmed through progress notes and the vaccination record, which indicated the specific vaccines and their lot numbers. During an interview, the Director of Nursing (DON) confirmed that the vaccines were administered despite the signed declination forms and progress notes indicating refusal. The DON acknowledged that staff should have reviewed the declination sheets more carefully and recognized the seriousness of administering vaccines against the resident's or legal guardian's wishes. The DON also verified the administration log and immunization record, confirming the error.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in deficiencies observed in the care of two residents. For Resident 144, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) when entering the resident's room, despite the presence of a contact precautions sign. Additionally, a Registered Nurse (RN) failed to perform proper hand hygiene and did not disinfect scissors used during wound care for the same resident. The RN admitted to not sanitizing the scissors and not performing hand hygiene between glove changes, citing unfamiliarity with the facility's supply locations as a contributing factor. For Resident 27, a CNA did not follow proper hand hygiene protocols during incontinence care. After removing a soiled incontinence brief and performing perineal care, the CNA did not remove soiled gloves and cleanse hands before touching clean items and equipment in the resident's room. This lapse in protocol was confirmed by the CNA during an interview with the surveyor. The facility's policies on infection prevention, control, and hand hygiene were not adhered to by the staff, as confirmed by the Director of Nursing (DON). The DON acknowledged that staff should wear gowns and gloves when providing care involving resident contact and that hand hygiene should be performed between glove changes and after handling soiled items. The DON also confirmed that reusable equipment should be sanitized before use.
Failure to Offer PCV20 Vaccine to Residents
Penalty
Summary
The facility did not ensure that flu and pneumonia vaccinations were reviewed, offered, or administered for three residents (R7, R11, and R21) as per CDC guidelines. Specifically, these residents were not offered the PCV20 (Prevnar 20) vaccine despite having received previous pneumococcal vaccinations (PPSV23 and PCV13). The medical records for these residents did not indicate that the PCV20 vaccine was offered or administered, which is a deviation from the facility's policy and CDC recommendations. The Director of Nursing (DON) confirmed that the residents should have been offered the PCV20 vaccine and that the documentation should have been included in their medical records. Resident 7, who had diagnoses including congestive heart failure, chronic kidney disease, pneumonia, and type 2 diabetes, received a PPSV23 vaccine in 2016 and a PCV13 vaccine in 2019 but was not offered the PCV20 vaccine. Resident 11, with diagnoses including COPD, multiple sclerosis, type 2 diabetes with neuropathy, and RSV pneumonia, received a PPSV23 vaccine in 2013 and a PCV13 vaccine in 2022 but was also not offered the PCV20 vaccine. Resident 21, diagnosed with Parkinson's disease, cancer, and dementia, received a PPSV23 vaccine in 2017 and a PCV13 vaccine in 2016 but was not offered the PCV20 vaccine. The DON acknowledged that the facility's vaccine policies and procedures need attention and that the PCV20 vaccination information was not included on the facility's consent/declination form.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure adequate fall prevention interventions for three residents. One resident, admitted with a left femur fracture and severe dementia, experienced multiple falls within a short period. Despite the falls, the facility did not implement new interventions promptly, and the resident fell again. The Director of Nursing confirmed that new interventions should have been added to the resident's care plan following the falls. Another resident, admitted after a fall at home resulting in a left femur fracture and hip surgery, had a rug with curled edges in their room, posing a trip hazard. The facility did not develop a comprehensive falls care plan that included the resident's preference and risk for keeping the rug. Staff expressed concerns about the rug, but no risk versus benefit statement was completed, and the care plan lacked detailed interventions. A third resident, with a history of tobacco dependence and brain cancer, required supervised smoking. However, smoking materials were found unsecured in the resident's room. Staff interviews revealed a lack of awareness and adherence to the facility's smoking policy, which mandates that smoking materials be kept locked in the medication cart.
Failure to Ensure QAPI Committee Meetings and Attendance Verification
Penalty
Summary
The facility did not ensure the minimum required members of the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly, as mandated. The facility failed to hold two of the four required QAPI meetings in the past year and six of the twelve monthly meetings per their policy. Additionally, for the two required QAPI meetings that were held, the facility was unable to provide verification of attendance for the required members. This deficiency had the potential to impact all 42 residents residing in the facility. Upon review, the surveyor found that the QAPI committee meeting sign-in sheets for the previous year were incomplete and lacked signatures. The facility's policy indicated that a core team, including the Executive Director, Director of Nursing, and other key personnel, should engage in monthly QAPI meetings. However, sign-in sheets for several months were missing, and the available sheets did not contain signatures. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of proper documentation and attendance verification for the QAPI meetings.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
