Tomahawk Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Tomahawk, Wisconsin.
- Location
- 720 E Kings Rd, Tomahawk, Wisconsin 54487
- CMS Provider Number
- 525334
- Inspections on file
- 20
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Tomahawk Health Services during CMS and state inspections, most recent first.
The facility failed to provide adequate supervision and safety measures for two residents with dementia and wandering risk. One resident with repeated elopement history exited the building without staff knowledge and without the Wanderguard alarm sounding, and staff later stated the alarm system was not detecting the tag properly. Another resident with severe cognitive impairment and a history of wandering was observed without proper footwear and without a Wanderguard, while staff could not produce complete documentation of the required 30-minute checks.
Food handling standards were not followed when prepared items in the walk-in cooler were covered but not labeled or dated, two opened milk containers in the milk cooler had no open or use-by dates, and an uncovered box of potatoes in dry storage had no label or date. The facility's labeling and dating guidelines required food to be dated upon receipt and labeled with the item name, prep/receipt date, and use-by date.
Infection Prevention and Control Failures During COVID Outbreak: Surveyors observed multiple infection control breakdowns, including staff entering COVID-positive rooms without N95s, missing airborne precaution signage, overdue N95 fit testing, improper catheter and wound care practices, and lack of laundry temperature logs. Surveyors also observed dirty linens uncovered in a shared shower room, open and partially used personal care items not labeled for individual residents, and a used surgical mask left on a PPE cart.
Surveyors found that staff placed continuous glucose monitoring sensors on the upper chest for multiple residents even though the manufacturer instructions said the device should be applied to the upper arms only, and the facility had no policy or physician approval for using alternative sites. Surveyors also observed an LPN and the DON administer insulin without priming pen needles, and the DON gave doses that did not match the ordered amounts for two residents. In another instance, Ferrous Sulfate was administered to a resident even though the order did not include a measurable dose.
Medication error rates were above the allowed threshold, with an observed rate of 22.22% during med pass. An LPN administered Ferrous Sulfate without confirming the ordered dose, and multiple insulin administration errors were observed, including failure to prime insulin pens and administration of incorrect insulin doses by both an LPN and the DON. The DON stated the facility tracks medication errors and reviews them in QAPI meetings.
Failure to Notify MD of Significant Weight Gain: A cognitively intact resident with atrial fibrillation and CHF had a physician order for daily weights and to call the MD for a 3-lb weight gain in 1 day or more than 7 lbs in 1 week. The record showed missed weights and two separate 1-day weight gains over 3 lbs, but there was no documentation that the provider was notified; the DON stated nursing staff were expected to report changes as ordered.
A resident with severe cognitive impairment eloped from the facility without staff knowledge and was later found outside by a reporting party. The resident wore a Wanderguard bracelet that did not alarm because the system was faulty, and the facility did not know the resident was missing until law enforcement contacted them. The surveyor determined the incident was reportable to the State Agency, but the facility failed to report it.
Failure to provide bed-hold notice after hospital transfer: A resident with recurrent falls and a hip fracture was transferred to the ED after acute changes in condition and later admitted to the hospital. The facility did not provide or document written bed-hold information for the resident or representative, and although the BOM said a phone call was made to the wife and she declined to hold the bed, that conversation was not documented in the chart.
Failure to follow fall-prevention care plan interventions for two residents. One resident with dementia, wandering, and repeated falls was observed ambulating without grip socks or shoes even though the care plan required proper grip footwear, and CNA staff did not intervene. Another resident with CVA-related weakness and dementia had a care plan for gripper strips at bedside, but the strips were not observed next to the bed after the resident had previously been found on the floor while trying to get to the bathroom.
Care Plan Not Updated for Current Needs: A resident with diabetes, amputations, contractures, pain, and urinary retention had a care plan that still listed opioids, hand splints, foot care, and urinal assistance even though opioids had been stopped, hand splints were refused, and a Foley catheter was in place. The MDS showed the Foley catheter, but the care plan was not revised to reflect the resident’s current status.
A resident with ESRD and dependence on renal dialysis did not receive required pre- and post-dialysis monitoring. The record showed repeated missing weights, incomplete vital signs, and absent dialysis assessments on multiple dialysis days, despite orders and facility policy requiring full pre-dialysis communication, weights, and vital signs. Staff, including the DON, confirmed that full vital signs and weights were expected before and after dialysis treatments.
The facility did not follow the posted menu and failed to notify residents of a menu change, affecting all 43 residents. The planned meal was replaced with an unannounced 'Meal of the Month,' leading to resident complaints. Menus were not easily accessible, and communication about changes was inadequate, as confirmed by staff.
A resident in a LTC facility was not provided with their preferred meal texture despite having intact cognition and repeatedly requesting a regular diet. The resident, admitted for rehabilitation, expressed dissatisfaction with the mechanically altered diet, which was not changed due to a lack of follow-up on their request. The facility acknowledged the oversight but did not document further actions to address the resident's preference.
A resident was improperly charged for transportation to a medical appointment, a service covered under Medicaid. The facility's van was unavailable, and an outside provider was used, requiring upfront payment. The resident's family paid the provider, but the facility lacked documentation of the resident's agreement to the charge. Transportation is included in the Medicaid daily rate, and the facility acknowledged the resident should be reimbursed.
A resident with type 2 diabetes was not monitored for blood glucose levels as per hospital discharge orders after readmission to the facility. Despite the care plan's inclusion of diabetes management interventions, the facility failed to perform daily glucose checks, which was acknowledged by the DON.
A facility failed to maintain proper infection control during wound care for a resident on Enhanced Barrier Precautions. The RN did not change gloves or perform hand hygiene after removing soiled dressings and before touching the resident's skin near open wounds. The RN acknowledged the oversight, and the DON confirmed the expectation of proper hand hygiene practices.
Failure to Supervise Residents at Risk for Elopement and Falls
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices were in place to prevent elopement and falls for two residents. One resident had severe dementia, a history of wandering and elopement attempts, and had previously been admitted to a secured memory care unit before being moved to an open wing after a successful Wanderguard trial. Her record showed repeated wandering risk assessments, severe cognitive impairment, and care plan interventions focused on redirection and activity. The record also documented prior elopement incidents in which she exited the building without the alarm sounding, along with multiple notes that her Wanderguard was inoperable or not functioning, with no clear documentation of follow-up when those problems were identified. On the day of the incident, the resident exited the facility without staff knowledge and without the Wanderguard alarm sounding. She was later found by a citizen approximately 0.7 miles from the facility, covered with about an inch of snow on her head, and police were called. Staff stated she had dressed herself and walked out without them knowing, and the facility stated it did not know why the alarm did not sound. The report states the door box alarm had been marked as functioning, but the signal strength for detecting the bracelet was not set sensitive enough. The resident was later returned to the facility, and her room was changed to the memory care unit. The facility also did not follow the care plan and supervision measures for another resident with dementia, PTSD, wandering, repeated falls, and noncompliance with treatment. That resident had a BIMS score indicating severe cognitive impairment and a care plan that included proper-grip shoes and interventions for wandering, but was observed without shoes and without gripper socks. The resident was seen moving around the hall and dining room near the front entrance, sitting on a couch about 20 feet from the entrance/exit door, and did not have a Wanderguard in place. Staff stated the resident was monitored by 30-minute checks, but documentation for several periods was missing, and staff could not produce proof of those checks for the dates reviewed.
Food Storage Items Were Not Labeled or Dated
Penalty
Summary
The facility did not ensure food was handled in accordance with professional food service standards. During an initial kitchen tour, the surveyor observed prepared food in the walk-in cooler that had been covered but was not labeled or dated, including individual pureed cake cups and vegetables in a serving container. The surveyor also observed two opened containers of milk in the milk cooler with no indication of when they were opened or when they should be used by, and an uncovered box of potatoes in dry storage with no label or date. The facility's Labeling and Dating guidelines stated that all foods should be dated upon receipt before being stored and that food labels must include the food item name, date of preparation/receipt/removal from freezer, and use-by date.
Infection Prevention and Control Failures During COVID Outbreak
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for all 44 residents. During a COVID outbreak, surveyors observed that airborne precaution signs were not posted for some residents diagnosed with COVID, and CNA staff entered rooms of COVID-positive residents wearing regular face masks instead of fit-tested N95 respirators. Surveyors also observed a resident in the memory care unit wander into another resident’s room where the resident had tested positive for COVID, and staff stated they were not aware of other interventions to keep wandering residents out of COVID-positive rooms. Surveyors observed additional infection control failures during resident care. A CNA entered the room of a resident on airborne precautions without wearing an N95 mask as indicated on the posted sign, and later acknowledged that the N95 should have been worn. PPE carts outside COVID-positive rooms contained only one size of N95 mask for all staff, even though staff were fit tested for proper N95 use and several direct care staff were overdue for annual fit testing. The DON, who was also the infection preventionist, confirmed that annual fit testing was required and that some staff had not been fit tested within the required timeframe. The report also documented failures during catheter care, wound care, laundry processing, and shared shower room practices. A CNA emptied a Foley catheter bag with the collection container placed directly on the floor and the catheter drain port touching the edge of the urinal. An LPN performed wound care and removed gloves without performing hand hygiene before putting on new gloves. Laundry staff and maintenance staff stated there were no logs of washer water temperatures or dryer temperatures, and neither could identify monitored temperatures for the older laundry equipment. Surveyors observed dirty linens uncovered in a shared shower room where a resident with dementia rummaged through the hamper, and observed open, partially used personal care products in the shower room that were not labeled with a resident’s name or dated when opened. Surveyors also observed a ripped bag of soiled incontinent briefs on top of a soiled linen cart and a used surgical mask lying on a PPE cart outside a resident’s room.
Improper Glucose Sensor Placement and Medication Administration Errors
Penalty
Summary
The facility did not provide care according to accepted standards of practice for 4 of 5 residents reviewed, including R2, R6, R21, and R39. Surveyors observed that continuous glucose monitoring sensors were placed on the upper chest for all four residents, even though the manufacturer insert provided by the facility stated the sensor was to be applied to the upper arms only. The DON stated staff had looked up alternative sites online, the facility did not have a policy for use of the devices, and no physician approval orders were obtained for using alternative sites. The residents’ care plans and physician orders did not mention that alternative sites could be used for the sensors. Surveyors also observed insulin administration that did not follow the facility’s insulin pen procedure. An LPN administered Lantus to R21 and R39 without priming the pen needles. The DON administered Lantus to R2 by dialing up 45 units and giving that amount even though the order was for 43 units twice daily, stating that was how the pen was primed. The DON also administered Lantus to R6 by giving 12 units when the order was for 10 units daily. In addition, R21 received Ferrous Sulfate 325 mg even though the physician order in the record stated only to take one tablet every other day and did not include a measurable dose; the DON stated staff should clarify the dose with the physician when an order has no dosage.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility did not ensure medication error rates remained below 5 percent, and the observed error rate was 22.22% for 4 of 5 residents reviewed during medication pass. The facility policy titled Medication Orders, revised 01/23, states that medication orders must include dose and dose form, and any dose or order that appears inappropriate considering the resident's age, condition, allergies, or diagnosis is to be verified with the prescriber. During observation on 03/18/2026, an LPN administered Ferrous Sulfate to a resident without confirming the physician order contained a dosage, and the resident's record did not contain documentation clarifying the correct milligram dose with the physician. The DON stated the expectation would be for staff to clarify the dose with the physician when an order has no dosage. The surveyor also observed multiple insulin administration errors involving Lantus, Humalog, and Toujeo. Facility policy for subcutaneous insulin administration states insulin pens are to be primed before use and the dose is then dialed to the prescribed amount. An LPN administered Lantus without priming the pen, and later administered Humalog and Toujeo without priming either pen, resulting in incorrect dosing. The DON also administered Lantus by placing the needle on the pen and pulling up extra units, stating that was how the pen is primed, and then administered 45 units to a resident whose order was for 43 units twice daily. In another observation, the DON drew up 12 units of Lantus and administered 12 units to a resident whose order was for 10 units daily, resulting in a wrong dose. The DON stated the facility tracks medication errors and addresses them at least quarterly in QAPI meetings.
Failure to Notify MD of Significant Weight Gain
Penalty
Summary
The facility did not notify the physician as indicated by the physician’s order for a significant weight increase for 1 of 13 residents, R46. R46 was admitted with a diagnosis that included atrial fibrillation, had a BIMS score of 15 out of 15, and was cognitively intact. The resident’s quarterly MDS listed a weight of 128 pounds, and the care plan addressed dehydration risk related to diuretic use with a goal of maintaining adequate hydration and stable weights. After a hospitalization for CHF, R46 was prescribed Furosemide 20 mg by mouth every morning on 2/20/26. The physician’s order dated 2/25/26 directed daily weights and to call the MD if there was a weight change of 3 pounds in 1 day or greater than 7 pounds in 1 week for CHF. The record showed no weights recorded and no documentation explaining why weights were not obtained on 3/8/26 and 3/10/26. On 3/13/26, R46’s weight increased from 128.4 pounds to 131.8 pounds, a gain of 3.4 pounds in one day, and on 3/17/26 the weight increased from 124.4 pounds to 127.8 pounds, a gain of 3.2 pounds in one day. Survey review found no documentation that the provider was updated about these weight changes, and the surveyor was not provided evidence that the provider had been notified. The DON stated that nursing staff were expected to report to the provider as indicated by orders.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a cognitively impaired resident who eloped from the facility without staff knowledge and was later found outside by a reporting party. The resident had a BIMS score of 00/15, indicating severe cognitive impairment, and was observed walking in the parking lot of a local thrift store with about an inch of snow on the resident's head. Police responded, EMS assisted with transport to the hospital for evaluation, and the facility was contacted only after law enforcement became involved. The resident had a Wanderguard bracelet that did not activate the alarm when the resident exited, and the facility reported that the alarm system was faulty. The facility was not aware the resident had left until notified by law enforcement, and the surveyor determined the event was reportable to the State Agency due to the high-risk circumstances and potential for serious harm or injury.
Failure to Provide Bed-Hold Notice After Hospital Transfer
Penalty
Summary
The facility did not provide written information specifying the bed-hold duration and payment policy to resident R49 or R49’s resident representative after R49 was transferred to the ED. The facility policy stated that, as part of the admission packet and at the time of transfer to the hospital, the facility would provide the resident and/or resident representative written information describing the State bed-hold policy and reserve bed payment policy, and would keep a signed and dated copy in the medical record. However, R49’s medical record did not contain a signed bed-hold policy, and there was no documentation that R49 or the representative received bed-hold information in writing or by phone. R49 was admitted with recurrent falls and a displaced left intertrochanteric hip fracture. After R49 developed increased lethargy, confusion, a non-reactive right pupil, and unstable vital signs, R49 was transferred to the ED and later admitted to the hospital. The hospital case manager later notified the facility that R49 would not be returning after discharge. The business office manager stated a phone call was made to R49’s wife on the day of transfer and that she declined to have the bed held, but this conversation was not documented in the medical record. R49’s representative later could not recall receiving bed-hold information or cost details and denied receiving a written notice.
Failure to Follow Fall-Prevention Care Plan Interventions
Penalty
Summary
The facility did not implement the comprehensive care plan for accident prevention for 2 residents reviewed for accidents. For R5, who had diagnoses including PTSD, unspecified dementia with behavioral disturbance, wandering, repeated falls, and noncompliance with medical treatment and regimen, the care plan last revised 12/09/2025 identified fall risk related to dementia, anxiety medication, and wandering and included the intervention to ensure shoes have proper grip. Record review showed R5 had multiple falls in January 2026 and documented wandering behaviors. On 03/17/2026, the surveyor observed R5 sitting in the dining room without grip socks or shoes and then ambulating in the dining room and back to the room without proper footwear, while CNA staff were nearby and did not intervene or remind R5 to put on shoes or grip socks. During interview on 03/19/2026, CNA F stated staff try to keep a close eye on R5, but R5 moves about independently and takes shoes off. For R43, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side, vascular dementia with behavioral disturbances, wandering, and generalized anxiety disorder, the care plan last revised 02/03/2026 identified fall risk related to weakness post CVA and dementia and included gripper strips at bedside. Record review showed R43 was found sitting on the floor in the room next to the bed on 02/27/2026 while attempting to get to the bathroom, and documented wandering behaviors were noted. On 03/19/2026, the surveyor observed R43 lying in bed resting and did not observe gripper strips on the floor next to the bed.
Care Plan Not Revised to Match Current Resident Status
Penalty
Summary
The facility failed to revise one resident’s care plan after completion of the MDS assessment. The resident was admitted with diagnoses including type 2 diabetes, contractures of both hands and knees due to palmar fascial fibromatosis, left below-the-knee amputation, cervical neck pain, back pain, neuropathy, enlarged prostate, and urinary retention. The resident’s most recent BIMS score was 8 of 15, indicating moderately impaired cognition. During observation, the resident was seen in bed with bilateral below-the-knee amputations and an indwelling Foley catheter, and stated that opioids had been taken away to try other things and that he did not want hand splints. The resident’s care plan still included opioid use for chronic pain, right hand splint use, diabetic foot care and daily foot inspections, a blue protective boot to the right foot, and assistance with a male urinal to avoid friction on plastic. Record review showed the last opioid dose was on 12/1/25, the resident was no longer receiving opioids, the resident refused hand splints, and the resident had an indwelling Foley catheter in place. The MDS dated [DATE] indicated use of an indwelling Foley catheter, but the care plan was not revised to reflect the resident’s current status. The VPS stated that the care plans should have been updated and old information removed.
Missed Pre- and Post-Dialysis Weights and Vital Signs
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. The facility did not ensure that the resident received care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences. The resident, R7, was admitted with diagnoses including acquired absence of kidney, chronic kidney disease stage 5, end stage renal disease, heart failure, history of malignant neoplasm of kidney, and dependence on renal dialysis. R7’s orders required a complete pre-dialysis assessment to be printed and sent with the resident to dialysis every Monday, Wednesday, and Friday, along with weekly weights and weekly vital signs on Friday shower day. Surveyor review of R7’s records showed repeated omissions in dialysis-related monitoring. In February, out of 12 dialysis days, vital signs other than blood pressure were not completed before dialysis on multiple occasions, 7 of 12 days had no pre-dialysis weight, and one pre-dialysis assessment was absent. In March, out of 7 dialysis days, vital signs were not completed before dialysis on every dialysis day, one day had no vital signs at all before the appointment, and 5 of 7 days had no pre-dialysis weight. Post-dialysis records also showed missing documentation, including 3 absent assessments in February, one day with no post-dialysis weight in February, and no post-dialysis weights in March. The record also showed an 11.4-pound weight loss on 03/04/26 and a 7.8-pound weight gain on 03/09/26. Staff interviews confirmed the expectation that full vital signs and weights should be completed before and after dialysis, and the DON stated this was the facility’s expectation.
Failure to Follow and Communicate Menu Changes
Penalty
Summary
The facility failed to follow the posted menu and did not notify residents of a menu change, affecting all 43 residents. On the day of the survey, the lunch menu was supposed to include Chinese Pork Chop Suey, egg rolls, fried rice, and diced pears. However, residents received a meal consisting of a hot dog, sauerkraut, parsley potatoes, a biscuit, and pudding with whipped topping. This discrepancy led to complaints from residents, including one who requested a bowl of cereal as an alternative because he was not informed of the menu change. The facility's policy requires menus to be planned in advance, posted in various locations, and followed, but these procedures were not adhered to. The issue was compounded by the facility's practice of serving a 'Meal of the Month,' chosen by a small group of Resident Council members, which was not communicated effectively to all residents. The dietary staff decided when this meal would be served, and it was not always suitable for all residents' dietary needs. Menus were posted in locations that were difficult for residents in wheelchairs to see, and there was no consistent method for informing residents of menu changes. The facility's staff, including the Nursing Home Administrator and Social Services Director, confirmed the lack of communication and participation in the Resident Council, contributing to the deficiency.
Failure to Honor Resident's Meal Preference
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not honoring a resident's request to change their meal texture. The resident, who was admitted for rehabilitation after a knee fracture and had intact cognition, expressed dissatisfaction with the mechanically altered diet they were receiving. Despite having requested a regular diet for five weeks, the resident continued to receive pureed meals, which they described as 'baby food.' The resident's dissatisfaction was noted by a staff member who stated that they could not change the meal without an updated order. The resident's progress notes indicated a complaint about the diet, and a referral to speech therapy (ST) was made. However, there was no follow-up on the resident's preference for a regular diet, and the ST evaluation notes did not address the issue after a certain period. The Nursing Home Administrator and Director of Nursing confirmed the lack of follow-up and noted that the resident had not made further complaints, but also acknowledged the absence of additional follow-up notes. Ultimately, the resident was offered the option to wait for another ST evaluation or sign a risk vs. benefit form to receive a regular diet.
Resident Charged for Medicaid-Covered Transportation Service
Penalty
Summary
The facility charged a resident, identified as R41, for transportation services to a medical appointment, which is a service covered under Medicaid. R41 was admitted to the facility with diagnoses including anemia, atrial fibrillation, and multiple myeloma, and had intact cognition as indicated by a BIMS score of 12/14. The facility's van driver was unavailable, and an outside transportation service was used, resulting in a charge to R41, which was not communicated to her in advance, either orally or in writing. The facility's admission packet and related documents did not list transportation services as a chargeable item, and the facility lacked a specific policy for transportation services. On the day of the appointment, the facility arranged for an outside transportation provider, TD C, to transport R41. The transportation provider required payment upfront, which was facilitated by R41's son-in-law. Upon arrival at the medical appointment, it was discovered that there was no appointment scheduled, and R41 was returned to the facility. Interviews with facility staff, including the Nursing Home Administrator and Business Office Manager, revealed that transportation is included in the daily rate for Medicaid residents, and the facility typically bills Medicaid for such services. However, due to outstanding bills, the transportation provider only accepted private pay, and there was no documentation of R41's agreement to the charge. The facility acknowledged the issue and indicated that R41 should be reimbursed for the transportation cost.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. A resident, who was admitted for rehabilitation after a knee fracture and had a history of type 2 diabetes, was readmitted to the facility following a hospital stay for sepsis, UTI, and acute kidney injury. The hospital discharge summary recommended daily blood glucose monitoring, which was not performed by the facility. The resident's care plan included interventions for diabetes management, but the Director of Nursing acknowledged that blood glucose levels had not been checked since the resident's readmission, missing the hospital's discharge order for daily testing.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Registered Nurse (RN) during wound care for a resident on Enhanced Barrier Precautions (EBP). The resident, who was admitted with multiple diagnoses including Multiple Sclerosis and stage 3 pressure ulcers, required specific infection control measures during care. During an observation, the RN did not change gloves or perform hand hygiene after removing soiled dressings and before donning new gloves. The RN also touched various surfaces and the resident's skin near open wounds without proper glove use or hand sanitization. The RN's actions were observed by a surveyor, who noted the lack of adherence to the facility's policy on EBP, which requires targeted gown and glove use during high-contact resident care activities. The RN acknowledged the oversight and the importance of using personal protective equipment to prevent infection. The Director of Nursing agreed with the surveyor's findings and confirmed that appropriate hand hygiene practices were expected during such procedures.
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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