Wheaton Franciscan Hc - Terrace At St Francis
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 3200 S 20th St, Milwaukee, Wisconsin 53215
- CMS Provider Number
- 525552
- Inspections on file
- 28
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Wheaton Franciscan Hc - Terrace At St Francis during CMS and state inspections, most recent first.
A resident with progressive MS and intact cognition refused a new bed when the facility implemented a building-wide bed replacement, but staff and a corporate representative proceeded to replace the bed and mattress despite her objections. After the change, the resident repeatedly reported severe back and hip pain attributed to the new bed, and documentation showed a significant increase in pain scores and frequent PRN Norco use during this period. When staff later agreed to switch her back to an older bed, an ISW and housekeeping moved numerous personal items out of her room, and housekeeping unilaterally took some of these belongings to a garbage chute room without the resident’s consent, contrary to her care plan that directed staff not to remove items without her participation. The resident became visibly upset when she discovered missing items and reported that not all of her belongings, including a bag of snacks, were returned, demonstrating a failure to respect her dignity, self-determination, and property.
A resident with a traumatic brain injury developed a full-thickness non-pressure wound on the right upper scapula that was initially assessed and treated by a wound care physician, with orders for weekly follow-up, repositioning, off-loading, and daily dressing changes. Facility policy required weekly documentation of wound appearance, measurements, treatment, and evaluation, and updating the plan of care with each intervention. However, after an assessment by the wound care physician, there was no comprehensive wound assessment documented for several weeks, and the wound was never added to the resident’s care plan, leaving no documented, person-centered interventions to promote healing. Interviews with the DON and an RN/unit manager confirmed the absence of these assessments and the missing care plan entry, while a surveyor observation confirmed the ongoing presence of the wound.
A resident with multiple comorbidities, a history of a healed stage 3 coccyx ulcer, and continuous bowel and bladder incontinence developed a new facility-acquired sacral pressure injury that was not comprehensively assessed or staged at onset, and the care plan was not revised with individualized interventions such as specific turning/repositioning and incontinence-check frequencies. Initial documentation of the wound lacked detailed assessment data, and hospice records contained no comprehensive wound assessment. When the wound physician later documented the ulcer as an unstageable full-thickness necrotic pressure injury and ordered a daily regimen including calcium alginate and collagen powder with a border dressing, the orders were not correctly transcribed to the TAR, collagen powder was omitted, and both the prior Mepilex-every-3-days treatment and the new daily treatment were signed as completed without clarification. An LPN reported performing only the less frequent border dressing, discontinuing the alginate due to resident discomfort without notifying the wound physician, and there was no evidence of consistent weekly RN wound assessments or a formal process to assign these assessments when the wound physician was absent.
Three residents experienced deficiencies in accident prevention due to staff failing to follow care plans and proper procedures. One resident suffered a femur fracture when a CNA transferred the resident alone with a sit-to-stand lift, did not use the required leg brace, and was not properly supported during transfers. Another resident, who is severely cognitively impaired, was repeatedly observed without a required floor mat at the bedside, despite care plan instructions. A third resident, also with severe cognitive impairment, was not toileted after meals as required, leading to self-transfer attempts. Staff training and documentation were incomplete or inaccurate, and care interventions were not consistently implemented.
Two residents submitted grievances regarding care issues, but the facility did not conduct thorough investigations, document corrective actions, or provide required written decisions. Grievances included concerns about catheter care, lack of bathing, delayed care, and an injury from equipment failure. Staff interviews revealed confusion about the grievance process, and required notifications and documentation were not completed.
A resident with multiple medical conditions and moderate cognitive impairment reported several instances of neglect, including incomplete showers and lack of assistance from a CNA. Despite these documented grievances, the facility did not report the allegations to the State Survey Agency or conduct a thorough investigation, as required by its own policies. Staff interviews confirmed the absence of a formal grievance process and failure to follow reporting protocols.
A resident's allegations of neglect, including incomplete showers, refusal of assistance with cleaning, and being left unattended, were documented but not thoroughly investigated or reported to the State Survey Agency as required by facility policy. Staff interviews confirmed the absence of a formal grievance process and a lack of proper investigation or reporting of these concerns.
A resident with severe cognitive and physical impairments, dependent on staff for all ADLs, was not provided with required assistance for oral care, shaving, or hair grooming. Despite a care plan and facility policy mandating daily hygiene and twice-daily oral care, observations and staff interviews confirmed these services were not performed or offered, with staff indicating that such care was often left to the resident's family.
A resident with a PICC line did not receive full dressing changes as required by professional standards and facility policy. Due to an incorrectly entered physician order, staff only changed the transparent portion of the dressing weekly, rather than the entire dressing. This error persisted until it was identified during a survey, with staff attributing the issue to the use of an incomplete order template and reliance on supervisors for order entry.
Two residents with or at risk for pressure injuries did not receive necessary assessment, treatment, or preventive interventions as required. One resident's wounds were not properly staged or assessed after hospitalizations, and prescribed treatments were missed. Another resident, identified as at risk, was repeatedly observed without required heel offloading boots, despite staff documentation stating otherwise. Staff interviews revealed inconsistent understanding of wound assessment and prevention protocols.
A resident with a suprapubic catheter did not have a StatLock device securing the catheter tubing as required by physician orders and facility policy, and staff failed to cleanse the spigot of the urinary collection bag with an alcohol pad after emptying it. These actions were observed by surveyors and confirmed through staff interviews, indicating a failure to provide appropriate catheter care.
Two CNAs did not perform required hand hygiene before, during, or after transferring a resident with a mechanical lift, nor did they clean the lift after use, in violation of facility infection control policies. The resident was dependent on staff for care and had multiple medical conditions, including cognitive impairment and a recent fracture. Despite recent staff training, the staff did not follow established protocols, and no explanation was provided for these lapses.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A discrepancy in the appearance of a resident's liquid Morphine led to an investigation involving police notification, medication removal, and staff and resident interviews. Although the facility stated that weekly audits of narcotic medication counts would be conducted, it was unable to provide documentation that these audits occurred, resulting in a failure to demonstrate a thorough investigation of the potential misappropriation.
Three residents were not protected from accident hazards due to the facility's failure to implement and maintain required fall interventions, investigate causes of skin injuries, and update care plans with recommended therapy and preventative measures. One resident was repeatedly observed without a fall mat or bed in the lowest position, another experienced multiple skin tears without investigation or new interventions, and a third sustained a fall without therapy evaluation or care plan updates.
Two residents experienced medication administration errors when an LPN gave one resident an excessive dose of liquid Potassium Chloride via an enteral tube without required pre- and post-flushes, and administered expired insulin to another resident without proper documentation of the vial's open date. These actions resulted in a medication error rate of 18.52 percent, exceeding the acceptable threshold.
Two cognitively impaired residents with histories of behavioral issues were observed engaging in intimate and inappropriate physical contact in a public area, without documented assessment of their capacity to consent or appropriate care plan interventions. Staff witnessed and reported the incident, but the facility lacked both a policy and completed assessments for capacity to consent to sexual intimacy, and failed to update care plans or implement behavior monitoring as required.
Two residents with cognitive impairment and behavioral issues did not have accurate or updated care plans reflecting their inappropriate sexual behaviors, despite documented incidents and facility policy requiring comprehensive, person-centered care plans. Staff interviews revealed care plans were not properly updated or maintained.
Several residents with pressure injuries did not receive timely skin assessments, and wound treatments were not initiated or documented as ordered. Staff were often unaware of existing wounds, and the Registered Dietician was not consistently notified of new or worsening pressure injuries, resulting in delayed nutritional interventions. Wound physician documentation was not readily available in the medical record, and facility practices did not align with established policies for pressure ulcer prevention and care.
A resident with a suprapubic catheter and a history of UTIs did not consistently receive or have documented physician-ordered catheter care, site cleaning, and prophylactic antibiotics. Over a 20-day period, multiple treatments and medication doses were missed or not recorded, and staff care practices did not align with orders. The resident experienced several UTIs and was ultimately hospitalized for acute encephalopathy due to a UTI.
Staff did not consistently follow infection prevention protocols, including the use of transmission-based and enhanced barrier precautions, and failed to properly clean and disinfect glucometers between resident uses. PPE carts were placed outside rooms without appropriate signage, and staff were often unaware of the required precautions or how to access this information. Additionally, there was no comprehensive process for tracking or analyzing infection data, and several staff members reported not receiving training on infection control procedures.
The facility failed to ensure proper wound care and documentation for several residents, including delayed initiation of physician-ordered treatments, incomplete wound assessments, and missing wound physician documentation in the medical record. Additionally, code carts on multiple floors were not consistently checked or maintained, with missing or expired supplies and unclear staff responsibility for monitoring, resulting in a lack of readiness for emergency situations.
Medication carts on multiple units were repeatedly found unlocked and unattended, including in open areas and rooms visible from hallways, with no staff present. LPNs responsible for the carts acknowledged that they should have kept them locked when not in direct supervision, in accordance with facility policy. The DON confirmed that leaving medication carts unsecured and unattended was not acceptable.
Surveyors found that the facility did not notify physicians when medications were missed or administered late for several residents, despite facility policy requiring such notification. Observations and record reviews showed that medications were not given as ordered, and staff interviews revealed inconsistent understanding and implementation of notification procedures. High nurse workloads and lack of support contributed to delays, but there was no documentation that physicians were informed or consulted about these medication issues.
A resident requiring substantial assistance with ADLs, including bathing, received only one bath over nearly six weeks despite being care planned for twice-weekly bathing. The resident, who had multiple medical conditions, reported feeling unclean and stated that repeated requests for bathing assistance were unmet. Staff interviews revealed that routine bathing was often missed due to staffing shortages, and required documentation of refusals or missed care was not completed. The DON confirmed the lack of records and stated that residents were expected to receive bathing as care planned.
Three residents who experienced falls did not have their incidents reviewed by the IDT, and their care plans were not updated with new interventions as required by facility policy. Although immediate post-fall assessments and notifications were completed, there was no documentation of root cause analysis or care plan modifications to prevent further falls, as confirmed by the DON.
Multiple residents did not receive their prescribed medications as ordered due to pharmacy delivery delays, lack of timely medication ordering, and staff not having access to contingency medication supplies. Medications were often administered late or not at all, with some being inappropriately crushed, and documentation was inconsistent. In some cases, residents self-administered critical medications without proper assessment or physician authorization, and staff were unable to enter or follow new orders in the electronic medical record, leading to further delays and omissions in care.
Three residents experienced significant medication errors due to the facility's failure to ensure timely administration and availability of prescribed medications. One resident did not receive a critical cancer medication for multiple days, with doses marked as given despite the medication being unavailable, and self-administration occurred without proper assessment or physician authorization. Another resident had a delay in starting IV antibiotics after hospital discharge due to pharmacy and communication issues, with inconsistent documentation of administration. A third resident missed several morning doses of multiple medications because they left for scheduled appointments before receiving them, and no adjustments were made to the medication schedule.
A resident with acute osteomyelitis and an infected foot ulcer missed four vancomycin infusions due to a delay in receiving a required trough level result from the laboratory. Despite multiple follow-up attempts by the DON, the lab result was not available in a timely manner, leading to the interruption of the resident's antibiotic therapy as ordered by the physician.
The facility exhibited a 32% medication error rate, affecting two residents. A resident received a discontinued Folic Acid supplement and had medications administered late, while another received excess Fluticasone Propionate and late blood pressure medication. The facility's vague medication administration policy contributed to these errors.
Two residents in the facility did not receive adequate pain management, as observed during a survey. One resident did not receive the prescribed topical pain relief medication correctly, and there were incomplete pain assessments and evaluations of pain interventions. Another resident experienced similar issues, with a lack of documentation regarding pain assessments and medication effectiveness. The facility's policy on pain management was not followed, leading to inadequate pain relief and documentation.
The facility failed to ensure accurate medication dispensing and proper equipment labeling for two residents. A resident received incorrect dosages of Hydrocodone due to discrepancies between the MAR and narcotic count sheet, affecting pain management. Additionally, the resident's Protonix was not administered as prescribed. Another resident's glucose monitor was improperly labeled, risking potential errors. The DON could not explain the discrepancies during the survey.
The facility failed to provide adequate care and documentation for two residents. One resident did not receive timely wound care as per hospital discharge instructions, leading to severe sepsis. Another resident did not have complete neurological checks following an unwitnessed fall, as required by facility policy. These deficiencies highlight lapses in following medical orders and documentation protocols.
The facility failed to provide adequate supervision and safety measures, resulting in multiple injuries for three residents. One resident sustained unexplained bruises and fractures, another fell due to an inaccessible reacher, and a third was improperly transferred by a single CNA despite requiring a Hoyer lift. The facility did not thoroughly investigate these incidents or ensure adherence to care plans, highlighting a lack of proper supervision and preventive measures.
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development and deterioration of pressure injuries. One resident's air mattress was incorrectly set, and no care plan revisions were made following the development of pressure areas. Another resident was not repositioned as per the care plan, and treatments were not completed. A third resident had a deep tissue injury with delayed treatment and no heel boots observed during the survey.
The facility failed to maintain sanitary conditions in food service, with a Food Service Associate not wearing a beard net and dish machines not reaching required temperatures. FSAs did not use test strips to verify sanitizer concentration, and logs were incomplete, lacking managerial oversight.
The facility failed to maintain an effective infection control program, with deficiencies in the Water Management Plan, infection surveillance, and adherence to infection control practices. The WMP was outdated and lacked necessary components, while infection surveillance did not adequately track or address increased infection rates. Staff failed to wear appropriate PPE and perform hand hygiene, and a resident's urinary catheter bag was not handled hygienically.
The facility failed to complete and submit quarterly MDS assessments within the required timeframe for six residents due to EMR downtime and staff absence. The RN/MDS-G was working on completing the overdue assessments, with a target date set for the transition to new ownership. The facility's Emergency Preparedness plan lacked specific instructions for MDS completion during EMR downtime, and despite additional documentation, the issue remained unresolved.
The facility failed to ensure that a licensed pharmacist's monthly drug regimen reviews were acted upon for five residents. The reviews contained recommendations for medication adjustments, but there was no evidence of physician response or action. The MRRs were either missing, not signed, or not acted upon by the physician, leading to deficiencies in medication management.
A resident with multiple sclerosis and anxiety was not involved in her care planning, leading to an incident where her personal belongings were removed without consent. This caused her to feel violated and anxious about staff entering her room. The facility failed to update her care plan to address these concerns until after a surveyor's intervention, contributing to her reluctance to leave her room.
A resident with multiple injuries, including bruising and fractures, was not reported to the State Survey Agency by the LTC facility. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the injuries were attributed to self-infliction or equipment issues without sufficient evidence. The facility's failure to report these injuries was identified during a surveyor's investigation.
A resident with multiple medical conditions, including dementia and heart failure, sustained unexplained bruises and fractures. The facility failed to report these injuries to the state agency or conduct a thorough investigation, as required by their policy. The facility's explanations for the injuries were not supported by evidence, and documentation was insufficient, with no comprehensive investigation conducted.
A resident with dementia and heart failure, receiving hospice care, was not properly communicated about significant changes in their condition. The facility failed to notify the resident's HCPOA and primary physician about multiple incidents, including a transfer to the ER, development of a pressure ulcer, and missed pain medication doses, violating their notification policy.
The facility failed to complete timely annual MDS assessments for two residents due to a lack of access to electronic medical records (EMR) and an inadequate emergency preparedness plan. The assessments, which were due in May, were not completed until July, resulting in a delay in reviewing and updating care plans. The facility's EMR Disaster and Downtime Process did not include instructions for handling MDS assessments during downtime.
A resident with a urostomy and PICC line was observed multiple times with their catheter bag visible from the hallway, not covered in a privacy bag. Despite the resident's intact cognition, the care plan was not updated to reflect their preference regarding the visibility of the catheter bag. The facility failed to ensure the resident's dignity and privacy, as the care plan did not document the resident's wishes, leading to a deficiency noted by the surveyor.
A resident with chronic respiratory failure was found to have unlabeled oxygen tubing and a dry humidification jar, contrary to the facility's policy. The facility's procedure requires labeling and periodic checking of the humidification jar, but these steps were not followed, as observed during the survey. The unit manager and nursing home administrator acknowledged the deficiency.
A resident received Ativan 0.5 mg every eight hours as needed without a stop date or documented rationale for extending the PRN order beyond 14 days, contrary to facility policy. The resident, with multiple diagnoses including anxiety disorder, was under hospice care, and the hospice team was responsible for medication orders. However, there was no communication or documentation from the hospice team regarding the rationale for the extended use of Ativan, leading to a deficiency noted by the surveyor.
A resident with multiple medical conditions and impaired decision-making skills was not offered routine dental care since admission, despite having poor oral health and expressing a desire for dental services. The facility's policy requires dental services to be available and documented, but there was no care plan or record of the resident being on the dental list. Staff interviews revealed a lack of communication and documentation, and the issue was only addressed after being highlighted by a surveyor.
A resident with Parkinson's Disease and dysphagia did not receive necessary assistive eating equipment at a facility. Despite a nutrition risk assessment indicating the need for special utensils and cups, these were not provided, leading to the resident's inability to eat independently. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, resulting in meals being left untouched.
The facility failed to coordinate hospice services for two residents, resulting in missing hospice visit notes and incomplete recertification of terminal illness. Staff were unaware of hospice schedules and lacked a designated liaison for communication. This led to care issues not being addressed timely, violating the facility's obligations under the hospice agreement.
Failure to Honor Resident’s Refusal of Bed Change and Mishandling of Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s rights to dignity, self-determination, and respect for her personal belongings during a facility-wide bed replacement. The resident, who has progressive multiple sclerosis, hypertension, and glaucoma, had a BIMS score of 15 indicating she was cognitively intact. When approached about changing her bed as part of a project to replace older beds, she explicitly refused, but her bed was nonetheless changed on 11/25/25 after facility staff and a corporate representative insisted that all beds had to be replaced. The Chaplain and DON were present when the bed and mattress were changed, and the Chaplain confirmed that the resident did not want her bed changed but it was done because beds throughout the facility were being replaced. Following the bed change, the resident repeatedly complained to multiple staff that the new bed was causing significant back and hip pain, stating she could feel the bars in her back and could not stand up. She reported these concerns to nurses, the Chaplain, and the NP. Progress notes document her complaints of increased pain in the right hip and lumbar area and a request for an x-ray, which was obtained and reviewed. Review of the MARs showed that prior to the new bed, her pain scores were consistently 0 with very limited PRN Norco use, but during the period she had the new bed, there was a marked increase in documented pain scores and frequent administration of PRN Norco 5/325 mg for breakthrough pain. The social worker later documented that the resident reported the new bed was causing back pain and that she preferred the older model and wanted it switched back. When the facility eventually agreed to switch the resident back to an older bed and mattress on 12/18/25, the process of moving her belongings was not handled in accordance with her care plan and rights. The resident had a care plan problem related to hoarding and a history of displacement, with an explicit approach to avoid removing items from her room without her participation. Despite this, the interim social worker and housekeeping staff moved multiple personal items from the bed, under and around the bed, and placed them in the hallway, and housekeeping then took some of these belongings to the garbage chute room as part of an effort to “clean” the room, without asking the resident which items could be discarded. The resident, who typically did not leave her room, came into the hallway visibly upset when she realized items were missing. Housekeeping acknowledged placing the resident’s belongings in the garbage chute room and then retrieving them after the resident became upset, but the resident reported that not all items were returned, including a bag with snacks she valued. The facility’s own resident rights policy states that residents are entitled to exercise their personal rights to the fullest extent possible and to always be treated with respect, kindness, and dignity, which was not followed in this situation.
Failure to Complete Weekly Wound Assessments and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive weekly assessment and care planning for a resident’s non-pressure wound in accordance with facility policy and physician orders. The facility’s skin policy dated 11/2022 requires licensed nursing staff to document weekly integumentary findings, including wound appearance, measurements, treatments applied, and evaluation, and to update the plan of care with each intervention. The resident, admitted with a traumatic brain injury and having a guardian, was seen by a wound care physician on 12/4/25 and identified as having a full-thickness non-pressure wound to the right upper scapula measuring 6 cm by 6 cm by 0.1 cm with light serous drainage and 10% necrotic tissue. On 12/11/25, the wound care physician documented that the wound measured 6 cm by 3 cm by 0.1 cm with light serous drainage and 20% slough, which was debrided, and recommended continued treatment with a gauze island border dressing, repositioning per facility protocol, and off-loading of the wound, with weekly follow-up. A subsequent wound care visit on 12/18/25 was rescheduled due to the resident’s refusal of wound evaluation. Despite these findings and orders, the resident’s medical record contained no comprehensive wound assessment after 12/11/25 through 1/6/25, even though the DON stated that the wound care doctor comes weekly and that either the RN manager or floor nurse would conduct wound rounds and assessments. The resident’s plan of care did not identify the non-pressure wound, and therefore contained no documented, person-centered interventions to promote healing or to evaluate whether interventions or treatments needed adjustment. Interviews with the DON and RN/unit manager confirmed that they could not produce any comprehensive wound assessments after 12/11/25 and that the wound had not been added to the care plan, with the RN/unit manager stating that the MDS nurse completes care plans but not knowing why the wound was not included. During an observation on 1/5/26, the surveyor noted two wound areas on the resident’s right upper scapula consistent with the 12/11/25 assessment, further confirming the ongoing presence of the wound without corresponding weekly assessments or care plan documentation.
Failure to Provide Comprehensive Pressure Injury Prevention, Assessment, and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury prevention and treatment consistent with professional standards of practice for one hospice resident with multiple comorbidities, including primary progressive MS, chronic kidney disease, osteoporosis, severe protein-calorie malnutrition, and cirrhosis. The resident was always incontinent of bowel and bladder and had a prior history of a stage 3 coccyx pressure injury that had healed earlier in the year. The care plan identified the resident as at risk for pressure ulcers and included general interventions such as encouraging peri hygiene with barrier cream after incontinence, observing skin for redness and breakdown, use of a low air loss mattress, heel floating, use of a pressure-relieving cushion, turning and repositioning during rounding, and use of a lift sheet. However, the care plan did not specify person-centered details such as the frequency of turning and repositioning or how often the resident should be checked and changed for incontinence, despite documentation that the resident was always incontinent. A new facility-acquired pressure injury to the sacrum/coccyx was identified on 12/11/25, documented as a full-thickness wound measuring 1.0 x 0.5 cm. The skin assessment summary did not include a comprehensive assessment: depth was not documented, wound bed color was marked as inapplicable, and the stage was entered as “Further assessment required.” Treatment ordered at that time was to cleanse with normal saline and apply zinc covered with a foam dressing, and a hospice nurse note indicated a new order for cleansing with normal saline, barrier cream to non-open areas, and Mepilex dressing. The December TAR showed the Mepilex treatment every three days was signed as completed through the end of the month. There was no comprehensive hospice documentation of the wound, and the resident’s care plan was not revised to reflect the new pressure injury or to add new, individualized interventions. An RN later stated that when new wounds are found, staff “just measure it” and “don’t stage wounds,” and there was no documentation of wound characteristics such as appearance or exudate at the time of discovery. On 12/18/25, the wound physician assessed the sacral wound and documented it as an unstageable full-thickness pressure injury due to necrosis, measuring 7 cm x 10 cm with moderate serous exudate and 20% thick adherent devitalized necrotic tissue. The physician ordered a dressing regimen including daily calcium alginate and collagen powder with a gauze island border dressing. The facility did not correctly transcribe these orders to the TAR: collagen powder was omitted, and both the original Mepilex every-three-days treatment and the new daily alginate regimen were signed out as completed concurrently. Staff did not clarify with the wound physician which treatment should be discontinued. An LPN later reported she had only been performing the three-times-weekly border dressing, had not been using the calcium alginate because the resident complained it burned, and had not contacted the wound physician; there was no documentation that any physician was notified that the ordered treatment was not being followed. Weekly comprehensive wound assessments and measurements were not consistently completed by an RN in the absence of the wound physician; the next documented assessment with measurements after 12/18/25 did not occur until 12/29/25, was entered by an LPN, and repeated the physician’s prior measurements and description. The DON acknowledged that nurses were only verbally told to assess wounds when the wound doctor would not be present and that there was no formal assignment or sign-out process for these weekly assessments.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that three out of five residents received adequate supervision and assistive devices to prevent accidents, as evidenced by multiple observations, interviews, and record reviews. One resident sustained a left femur fracture when a CNA transferred the resident alone using a sit-to-stand lift, despite care instructions requiring two staff for transfers. The lift lost power during the transfer, and the resident's leg gave out, resulting in a fracture. Following the incident, the resident was observed multiple times without the required leg brace, and staff were seen operating the mechanical lift incorrectly, including not supporting the resident's injured leg and not following proper lift procedures. Additionally, a physician-ordered follow-up x-ray was not obtained, and documentation indicated staff were marking the x-ray as completed when it was not. Staff training on lift use was incomplete, and agency staff did not receive competency evaluations. Another resident, who is severely cognitively impaired and dependent for care, was observed repeatedly without a floor mat at the bedside, contrary to the care plan and CNA worksheet instructions. The floor mat, intended as a fall prevention measure, was found folded and not in use during multiple observations across different shifts. Staff did not place the mat at the bedside during or after care, and when questioned, a CNA stated she had not moved the mat. The issue was brought to the attention of nursing management, but the mat remained unused at the resident's bedside throughout the survey period. A third resident, also severely cognitively impaired and at risk for falls, was not toileted after meals as required by the fall prevention care plan. The resident was observed self-transferring to the toilet without staff assistance, despite being care planned for substantial assistance with transfers and toileting. Staff did not follow the intervention to toilet the resident after meals, and the resident was found on the toilet by a CNA, who then instructed the resident not to self-transfer in the future. The failure to follow the toileting intervention was confirmed by staff interviews and direct observation.
Failure to Provide Required Written Grievance Decisions and Investigations
Penalty
Summary
The facility failed to ensure that all written grievance decisions included the required elements such as steps taken to investigate the grievance, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not, any corrective action taken, and the date the written decision was issued. This deficiency was identified for two residents who had submitted grievances regarding their care and services. In both cases, the facility did not conduct thorough investigations, did not document corrective actions, and did not provide written decisions to the residents or their representatives. One resident, who had multiple complex medical diagnoses including hypertension, heart failure, and chronic pain, had a grievance submitted by her daughter regarding inadequate catheter care and lack of bathing. The grievance was acknowledged by the administrator through a phone call, but there was no documentation of an investigation, staff interviews, or corrective actions taken. The only notification provided was verbal, and no written resolution was issued as required by facility policy. Another resident, with diagnoses including heart disease, atrial fibrillation, anemia, hypothyroidism, depression, and dementia, had multiple grievances submitted by herself and her daughter. These grievances included concerns about delayed care, lack of regular care conferences, and an incident resulting in a femur fracture. The facility's documentation did not show that thorough investigations were conducted or that written notifications of resolutions were provided. Interviews with staff revealed confusion and lack of clarity regarding responsibility for the grievance process, and the required follow-up actions and documentation were not completed.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to ensure that allegations of neglect involving a resident were immediately reported to the Administrator and/or Grievance Officer and submitted to the State Survey Agency as required by policy. Record review and interviews revealed that a grievance dated 8/27/25 documented multiple concerns, including incomplete showers, refusal by a CNA to assist a resident with cleaning up spilled food, and another resident being left unattended when requesting assistance to prepare for therapy. Despite these documented allegations, the facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report or a Misconduct Incident Report to the State Survey Agency. The facility's Abuse Prevention and Abuse Investigation and Reporting policies require that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the Administrator or designee and to the State Agency within specified time frames. The policies also require that findings of investigations be reported in writing within five working days. However, interviews with facility staff, including the Social Worker and Nursing Home Administrator, confirmed that there was no formal grievance process in place and that the allegations of neglect were not reported or thoroughly investigated as required. The resident involved had a history of significant medical conditions, including atherosclerotic heart disease, paroxysmal atrial fibrillation, iron deficiency anemia, hypothyroidism, major depressive disorder, and dementia. The resident was moderately cognitively impaired but alert and oriented at the time of the survey. The surveyor found that the facility's failure to report and investigate the allegations of neglect constituted a deficiency in compliance with regulatory requirements.
Failure to Investigate and Report Allegations of Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of neglect involving a resident, as required by its own policies and federal and state regulations. The surveyor reviewed a grievance dated 8/27/25, which documented several concerns: showers not being completed with one CNA documenting multiple refusals while other staff were able to accomplish the task, a resident reporting that a CNA refused to help clean up spilled food, and another resident stating that a CNA left her unattended when she wanted to get up for therapy. Additionally, a grievance from 8/8/25 noted that a resident was late to lunch because a CNA paused care to use the phone. These grievances were entered into the facility's log, and at least one resulted in a documented counseling session for the CNA involved. Despite these documented concerns, the facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report or a Misconduct Incident Report to the State Survey Agency. The facility's policies require immediate reporting and thorough investigation of all allegations of abuse, neglect, or mistreatment, including interviews with the resident, witnesses, and staff, as well as submission of findings to the appropriate agencies within specified timeframes. However, the surveyor found that these steps were not followed, and the allegations were not reported as required. Interviews with facility staff revealed that the social worker was only involved in entering grievances into a spreadsheet and not in the investigation process. The Nursing Home Administrator confirmed that there was no formal grievance process in place at the time and acknowledged that the allegations of neglect were not thoroughly investigated or reported to the State Survey Agency. No additional information was provided to explain the lack of investigation and reporting.
Failure to Provide Required ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis and spastic paraplegia, who was assessed as being dependent on staff for all activities of daily living (ADLs) including oral hygiene, grooming, and shaving, did not receive the necessary assistance for these tasks. The resident's care plan specified total assistance with grooming, oral care twice daily, and shaving every other day. Despite these documented needs and facility policy requiring daily personal hygiene and twice-daily oral care, observations and interviews revealed that these services were not provided as required. Surveyor observations over two consecutive days showed that the resident was not offered or provided with oral care, shaving, or hair brushing/combing during morning care routines. The resident was repeatedly observed with unshaven facial hair and disheveled hair, and confirmed that oral care was not performed before breakfast. Staff interviews further indicated a lack of awareness or adherence to the care plan, with a CNA stating that oral care was performed only every other day and expressing uncertainty about the availability of oral swabs for residents unable to use a toothbrush. The CNA also reported that shaving and hair brushing were typically performed by the resident's wife rather than facility staff. The facility's own policy and the resident's care plan both required staff to provide and document daily personal hygiene and oral care, as well as regular shaving and grooming. However, direct observations and staff interviews confirmed that these essential care activities were not consistently performed or offered, resulting in the resident not receiving the necessary services to maintain good grooming and hygiene as required.
Failure to Provide Complete PICC Line Dressing Changes per Standards
Penalty
Summary
A deficiency occurred when a resident with a right upper extremity peripherally inserted central catheter (PICC) did not receive dressing changes in accordance with professional standards of practice. Upon the resident's readmission, the physician's order for PICC line care was incorrectly entered, specifying only the transparent portion of the dressing to be changed weekly, rather than the entire dressing as required. Facility staff, including LPNs and CNAs, followed this order and only changed the transparent cover, not the full dressing, for several weeks. The facility's own policy and standard practice require the entire dressing to be changed every 5-7 days or sooner if compromised. The error in the order entry was attributed to the use of a pre-set order template in the facility's electronic library, which only referenced the transparent dressing. Staff interviews revealed that the process for entering orders involved supervisors and higher-level staff, and the LPNs relied on these orders for care delivery. The deficiency was identified during a surveyor's observation and interviews, which confirmed that the resident's entire PICC line dressing had not been changed weekly since readmission, contrary to both facility policy and accepted standards of care.
Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and to promote healing for two residents, both with significant risk factors and existing pressure injuries. For one resident with multiple sclerosis and spastic paraplegia, there were multiple instances of inaccurate or incomplete wound assessments, including incorrect staging of pressure injuries and lack of detailed wound bed descriptions. After hospitalizations, assessments were delayed, and some areas previously identified as pressure injuries were not reassessed by a registered nurse or wound specialist until several days after readmission. Additionally, prescribed treatments were not consistently administered, as observed when a nurse failed to apply the ordered treatment to a pressure injury on the resident's right lateral foot. During morning care, staff did not apply skin protectant as ordered, and the nurse manager confirmed that this should have been done. For the second resident, who was at risk for pressure injury development due to immobility, incontinence, and recent fracture, staff failed to implement required preventive measures. The resident's care plan and CNA worksheet specified the use of heel suspension boots and offloading of heels while in bed. However, repeated observations by the surveyor over several days found the resident in bed without the boots on and heels not offloaded. Despite this, nursing staff documented in the treatment administration record that the boots were in place and heels were offloaded, which was inconsistent with direct observations and staff interviews. The LPN confirmed that if the resident refused the boots, this should have been documented, but there was no such documentation. The facility's policy on pressure injury assessment and treatment did not address the required assessment process upon admission or readmission, nor did it specify the necessary components of a pressure injury assessment. Interviews with nursing staff revealed inconsistent understanding and application of wound assessment standards, including staging and wound bed description. These failures resulted in inadequate monitoring, documentation, and implementation of pressure injury prevention and treatment protocols for residents at risk or with existing wounds.
Failure to Provide Proper Catheter Care and Adhere to Physician Orders
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, spastic paraplegia, and neuromuscular dysfunction of the bladder, who had a suprapubic catheter, did not receive care in accordance with physician orders and facility policy. The resident's care plan and physician orders required the use of a StatLock device to secure the catheter, to be changed weekly and as needed. During surveyor observations, the resident was found without a StatLock securing the catheter tubing, and staff did not notice its absence until it was pointed out by the surveyor. Additionally, during the process of emptying the resident's urinary collection bag, a CNA failed to cleanse the end of the spigot with an alcohol pad before returning it to the holder, contrary to facility policy and the procedure described by the Director of Nursing. The CNA emptied the urine into a graduate and then into the toilet, but did not clean the spigot, which was confirmed by both observation and staff interview. These actions did not meet the standards outlined in the facility's urinary catheter care policy.
Failure to Follow Hand Hygiene and Equipment Cleaning Protocols During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to the facility's infection prevention and control policies during the transfer of a resident with multiple medical conditions, including dementia, heart disease, and a recent femur fracture. During an observed transfer using a mechanical lift, two CNAs placed gloves on without performing hand hygiene beforehand, did not perform hand hygiene after removing gloves, and failed to perform hand hygiene at other required points during resident care. Additionally, after the transfer, the mechanical lift was not wiped down as required by facility policy. Both CNAs exited the resident's room without performing hand hygiene, and one CNA handled resident care items and assisted the resident without hand hygiene or glove use. The resident involved was moderately cognitively impaired, dependent on staff for transfers and personal care, and at risk for pressure injuries. The facility's policies clearly require hand hygiene before and after resident contact, after glove removal, and after use of equipment such as mechanical lifts. Despite recent staff training on hand hygiene, the observed staff actions did not comply with these protocols, and no explanation was provided by the facility for the failure to follow infection control procedures.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document Investigation of Narcotic Discrepancy
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible misappropriation of a resident's narcotic medication was thoroughly investigated. A discrepancy was identified in the appearance of a resident's liquid Morphine, which appeared lighter in color than usual. The facility reported the incident to the State Agency, notified the police, removed the medication from the cart, and conducted interviews and pain assessments. The facility's investigation concluded that there was no substantiated evidence of misuse and suggested the color change could be due to the medication's age and infrequent use. However, the facility committed to conducting weekly audits of narcotic medication counts for six weeks to enhance monitoring, including documentation of the color and consistency of all liquid medications. When the surveyor requested documentation of these audits, the facility was unable to provide them. Despite multiple requests and attempts to locate the records, the facility could not produce evidence that the weekly audits were performed, leaving it unclear whether a thorough investigation into the potential misappropriation was completed.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
Three residents were not adequately protected from accident hazards, and the facility failed to provide sufficient supervision and interventions to prevent accidents. One resident with vascular dementia, anemia, and depression, who was assessed as being at risk for falls and required extensive assistance with activities of daily living, was observed multiple times without required fall interventions in place. Specifically, the resident's bed was not maintained in the lowest position, and a fall mat was not present at the bedside, despite these being recommended and documented interventions in the care plan following a previous unwitnessed fall. Staff interviews confirmed a lack of awareness and implementation of these interventions. Another resident with chronic atrial fibrillation and on blood thinning medication experienced multiple skin injuries, including skin tears and bruising, during care activities such as repositioning and transfers. There was no documentation of investigations into the causes of these injuries or implementation of new interventions to prevent further incidents. Interviews with nursing staff and review of records revealed that no root cause analysis or preventative measures were documented or put in place following these events. A third resident with dementia, weakness, and a history of repeated falls sustained an unwitnessed fall resulting in a large bruise to the forehead and face. Although a root cause analysis recommended therapy evaluations and adjustments to the toileting schedule, the care plan was not updated to reflect these interventions, and no therapy evaluation was conducted after the fall. Staff interviews confirmed that therapy services were not initiated as recommended, and the care plan lacked documentation of revisions or implementation dates for new interventions.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as evidenced by an observed error rate of 18.52 percent during the survey. Two residents were directly affected by medication administration errors. One resident was administered 15 milliliters of liquid Potassium Chloride via an enteral feeding tube, despite the physician's order specifying only 3.75 milliliters. Additionally, the enteral tube was not flushed with water prior to or immediately after medication administration, contrary to facility policy, with the post-administration flush occurring approximately one hour later. The resident was receiving tube feeding at the time, which was stopped for medication administration, but the required flushing steps were not followed. Another resident was given insulin (Humalog/Lispro) that was past its discard date, as indicated on the packaging. The insulin vial also lacked an open date, which is required by facility policy to ensure proper tracking and timely disposal. The LPN responsible for administering these medications did not adhere to established protocols for medication administration, including checking expiration dates and following procedures for enteral tube medication delivery. These actions were confirmed through direct observation, staff interviews, and review of physician orders and facility policies.
Failure to Assess Capacity and Protect Residents from Potential Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from potential abuse when they were observed engaging in physical intimacy, including holding hands, kissing, and inappropriate touching, without documented assessment of their capacity to consent. Both residents had significant cognitive impairments, as evidenced by low or incomplete BIMS scores, and both had histories of behavioral issues, including sexual inappropriateness and wandering. Despite these factors, the facility did not complete or have a policy for assessing capacity to consent to sexual intimacy for either resident. Staff members observed the two residents engaging in intimate behaviors in a public area, with multiple staff confirming the incident and reporting it to supervisory staff. The care plans for both residents did not address sexual inappropriateness or include behavior monitoring, despite documented histories of such behaviors. The facility's abuse prevention policy required investigation of sexual activity involving residents with cognitive impairment, but this was not followed as required assessments were not completed. Interviews with staff revealed that the incident was witnessed by several employees, who noted the residents' prior behavioral histories and reported the event to the appropriate personnel. However, there was a lack of timely intervention and documentation regarding the residents' ability to consent, and the care plans were not updated to reflect the risk or address the behaviors observed. The facility also lacked a specific policy on assessing capacity to consent for sexual intimacy, contributing to the failure to protect the residents from potential abuse.
Failure to Maintain Accurate Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to ensure that two residents had accurate and up-to-date care plans, as required by policy. One resident with a history of sexually inappropriate touching of other residents was observed engaging in physical contact with another resident, but his care plan was not updated to reflect inappropriate sexual behaviors. The care plan for this resident previously included impaired behavior related to touching other residents, but this was marked as resolved and not revised to address ongoing or new concerns. The resident's Minimum Data Set (MDS) also did not indicate behaviors directed toward other residents, despite documented incidents. Another resident, who had dementia with behavioral disturbances and daily wandering behaviors, did not have any care plan interventions addressing sexual inappropriateness, even though she was involved in the observed incident. Staff interviews confirmed that the care plans were not appropriately updated and that there was uncertainty regarding the resolution and documentation of behavioral issues. The facility's policy required comprehensive, person-centered care plans to be developed and revised based on assessment findings, but this process was not followed for these residents.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for residents with existing wounds. Multiple residents were affected by lapses in timely skin assessments, initiation and documentation of wound treatments, and communication among staff and with the Registered Dietician (RD). For example, one resident was readmitted to the facility with pressure injuries, but skin assessments were not completed in a timely manner, treatments were not initiated or completed as ordered, and weekly comprehensive wound assessments were not documented. The facility staff were unaware of a pressure injury observed by the surveyor, and documentation did not match the wound physician's findings. The wound physician's documentation was not readily available in the resident's medical record, further hindering appropriate care. Another resident developed Stage 2 pressure injuries to the buttocks, but these were not comprehensively assessed, and treatment orders were not implemented as required. Treatments were inconsistently signed out as completed, and the RD was not informed of the new or existing wounds, resulting in delayed nutritional assessments and interventions. The surveyor observed additional pressure injuries that staff were unaware of, and the wound physician's documentation was not present in the medical record. The resident reported ongoing issues with skin integrity that were not being regularly evaluated by nursing staff. A third resident developed a Stage 3 pressure injury and an unstageable pressure injury, but treatment was not started until several days after identification. Treatments were not consistently documented as completed, and the RD was not notified of the wounds. The facility's own policies required timely skin assessments, initiation of protective dressings, notification of the healthcare provider and RD, and comprehensive documentation, but these steps were not followed. The surveyor's findings were based on direct observation, interviews with staff and residents, and review of medical records, all of which demonstrated a pattern of failure to provide appropriate pressure ulcer care and prevention.
Failure to Provide and Document Ordered Catheter Care and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not consistently receive physician-ordered catheter care and related treatments. The resident, who has multiple sclerosis, neuromuscular dysfunction of the bladder, paraplegia, and a history of urinary tract infections (UTIs), had several orders in place for catheter irrigation, site care, monitoring for infection, and prophylactic antibiotics. Surveyors found that over a 20-day period, there were multiple instances where these treatments and medications were not documented as completed, including missed catheter irrigations, site cleanings, and doses of prescribed antibiotics. The facility's own catheter care policy requires documentation of care provided, observation for complications, and prompt reporting of infection signs. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed numerous dates where required care was not recorded. Interviews with staff revealed inconsistencies in the care provided, with a CNA describing a cleaning process that did not align with the physician's orders. The Director of Nursing acknowledged the resident's frequent UTIs but did not provide an explanation for the missed documentation or treatments. During the review period, the resident experienced multiple UTIs and was prescribed several courses of antibiotics. Ultimately, the resident was transferred to the hospital due to acute encephalopathy resulting from a UTI. The surveyor also noted a lack of ongoing urology involvement and follow-up, despite the resident's complex medical needs and repeated infections.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to consistently implement and follow infection prevention and control procedures, specifically regarding transmission-based precautions (TBP), Enhanced Barrier Precautions (EBP), and the cleaning and sanitizing of glucometers. Observations revealed that personal protective equipment (PPE) carts were placed outside several residents' rooms without appropriate signage indicating the type of precautions in place. Multiple staff members, including RNs, LPNs, CNAs, and other personnel, were unaware of the reasons for the precautions or the correct procedures to follow. The Director of Nursing (DON) and Infection Preventionist (IP) confirmed that signage should have been present and that staff should have been informed of the required precautions, but acknowledged that the electronic medical record (EMR) system was difficult to navigate and that staff were not always adequately informed during shift reports. The facility also failed to ensure proper infection prevention procedures related to the cleaning and sanitizing of glucometers. Multiple instances were observed where LPNs used glucometers on several residents without cleaning or disinfecting the devices between uses, and without placing a clean barrier between the glucometer and resident surfaces. Some staff were unaware of where to find appropriate cleaning agents, and others used disinfecting wipes incorrectly, not adhering to the required contact time or allowing the device to air dry. Several staff members reported not receiving any training on the facility's infection control policies or procedures, and agency staff in particular noted a lack of orientation or instruction regarding these protocols. Additionally, the facility did not maintain a comprehensive process for tracking, trending, or analyzing infection data as required by its own policies. Review of the infection control documentation revealed no evidence of infection tracking or data analysis for the period reviewed. The DON and IP both confirmed the absence of a comprehensive infection surveillance and analysis process, despite expectations that such a system should be in place.
Deficient Wound Care and Emergency Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate treatment and care for residents with non-pressure wounds in accordance with professional standards and physician orders. For three residents reviewed, there were significant lapses in wound assessment, documentation, and timely initiation of ordered treatments. In one case, a resident developed a non-pressure wound to the lower mid spine, but a comprehensive assessment was not completed, and no wound measurements or descriptors were documented. The wound physician's treatment order was not initiated until seven days after it was given, and subsequent wound documentation was inconsistent and incomplete. Additionally, wound physician and dermatology documentation were not available in the resident's medical record, and the dietician was not notified of the wound, leading to gaps in nutritional intervention. Another resident developed a rash to the right leg, which was not comprehensively assessed, and the wound physician's treatment order was also delayed by seven days. Documentation of wound assessments was inconsistent, and the wound physician's notes were not present in the medical record. The resident reported ongoing symptoms, such as itching and redness, and was not consistently receiving ordered treatments or interventions. A third resident was admitted with multiple wounds, but no admission skin assessment was completed until five days after admission. Wound descriptions were lacking, and treatments were not consistently documented as administered. Wound physician documentation was also missing from the medical record. The facility also failed to maintain and monitor emergency medical equipment, specifically code carts, in accordance with professional standards. Observations revealed that code carts on multiple floors were not consistently checked or documented as maintained, with missing inventory checklists, expired or missing supplies, and unclear staff responsibility for monitoring the carts. In some cases, essential equipment such as oxygen tanks was missing or empty, and documentation of code cart checks was incomplete or absent. Staff interviews confirmed a lack of clarity regarding who was responsible for code cart maintenance, and there was no evidence of a systematic process to ensure code carts were fully supplied and ready for use.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on the first, second, and third floors were left unlocked and unattended on multiple occasions. On the third floor, a medication cart was found unlocked and unattended at the nurses station with no nursing staff present. The responsible LPN confirmed he had left the cart unlocked while administering medication elsewhere and acknowledged it should have been locked. On the first floor, a medication cart was found unlocked and unattended in the charting room, with the room door open and no staff present. Similarly, on the second floor, a medication cart was observed unlocked and unattended, and the responsible LPN stated she thought she had locked it but had left to do charting in the nursing office. Additionally, the medication room on the first floor was found with its door fully open, and an unlocked, unattended medication cart was visible and accessible from the hallway. No staff were present in the medication room or at the nurses' station nearby. When the responsible LPN returned, she confirmed the cart should not have been left unlocked and unattended, as it could be accessed by residents or others. The Director of Nursing also stated that leaving medication carts unlocked and unattended was not acceptable. Facility policy requires medication carts to be kept closed and locked when out of sight of the medication nurse or aide, and no medications are to be kept on top of the cart.
Failure to Notify Physician of Missed or Late Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to notify residents' physicians when medications were not administered as ordered for seven residents. The facility's policy required documentation and physician notification for withheld, refused, or late medications, but did not address situations where medications were unavailable. In multiple cases, residents missed scheduled doses due to being out of the facility, medication unavailability, or late administration, and there was no evidence in the medical records that physicians were notified of these missed or late doses. For example, one resident with multiple complex diagnoses missed several doses of critical medications, including blood pressure and antiviral drugs, without physician notification. Direct observation and record review revealed that medications were administered outside the prescribed time frames, sometimes several hours late, and documentation of physician notification was consistently lacking. Interviews with nursing staff and the DON confirmed that the expectation was to notify the physician when medications were not administered as ordered, but this was not consistently done. In some cases, staff were unclear about the policy or stated there was no expectation to notify the physician, despite the facility's policy and the DON's stated expectations. The survey also documented workflow and staffing challenges, with nurses reporting high workloads and insufficient support, which contributed to delays in medication administration. Despite these challenges, there was no documentation that physicians were consulted regarding late or missed medications, and no evidence that the facility's policy was followed in these instances. The lack of physician notification placed residents at risk for unmet treatment needs, as the physician was not given the opportunity to address or revise treatment plans in response to missed or late medication doses.
Failure to Provide Routine Bathing Services Due to Staffing and Documentation Lapses
Penalty
Summary
The facility failed to provide routine bathing services to one resident who required substantial to maximum assistance with activities of daily living, including bathing. The resident, who was admitted with diagnoses of cellulitis of the right lower limb, morbid obesity, and chronic kidney disease, was care planned to receive a bed bath or shower twice weekly. Review of the resident's records showed that only one bath was documented during a period of nearly six weeks, with no documentation of refusals or reasons for missed baths. The facility's own procedures required documentation of bathing, refusals, and notification of supervisors if a resident declined care, but these steps were not followed. Interviews with the resident confirmed that she had only been bathed once since admission and had repeatedly requested assistance, but staff did not return to provide care. Multiple CNAs interviewed acknowledged that residents were supposed to be bathed twice weekly but cited staffing shortages as a barrier to completing all assigned baths. The Director of Nursing confirmed the lack of documentation for additional baths and stated that residents were expected to be assisted with bathing according to their care plans.
Failure to Conduct Root Cause Analysis and Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that a root cause analysis was conducted and care plans were updated following falls experienced by three residents. According to facility policy, all accidents and incidents involving residents are to be investigated, discussed by the interdisciplinary team (IDT) at the next scheduled meeting, and care plans should be reviewed and updated with individualized interventions after each fall. However, documentation revealed that after each resident's fall, there was no evidence of IDT review, root cause analysis, or updates to the residents' care plans to address the incidents. One resident with chronic kidney disease and type 2 diabetes, who was severely cognitively impaired, experienced a fall after slipping in the bathroom. Although immediate post-fall assessments and notifications were completed, there was no documentation of IDT review or care plan updates. Another resident with heart failure and chronic pulmonary embolism, also severely cognitively impaired, had an unwitnessed fall while coming from the bathroom. Similarly, post-fall assessments were performed, but no additional interventions were added to the care plan, nor was there evidence of IDT discussion. A third resident, cognitively intact with persistent atrial fibrillation and type 2 diabetes, fell out of bed, sustained a head wound, and was sent to the emergency department. Again, while immediate clinical responses were documented, there was no indication of subsequent IDT review or care plan modification. During an interview, the DON confirmed that the IDT had not addressed any of the referenced falls and that the residents' care plans had not been updated with new interventions to prevent further falls. This lack of follow-through on facility policy and federal requirements created the potential for continued falls among these residents.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to maintain adequate pharmaceutical services by not ensuring that medications were available and administered as ordered for multiple residents. Several residents did not receive critical medications, such as antibiotics, anticoagulants, and pain medications, due to issues including delayed pharmacy delivery, lack of timely medication ordering, and staff not having access to the contingency medication machine. In some cases, medications were not administered because they were not available in the facility, and staff failed to notify physicians or document the reasons for missed doses. For example, one resident did not receive vancomycin and ertapenem as ordered due to delays in obtaining necessary lab results and pharmacy delivery, while another resident missed doses of glaucoma eye drops because the medications were not on hand. Medication administration observations revealed a high error rate, with medications being given significantly outside the prescribed time windows and some medications being documented as administered when they were not actually given. Additionally, medications that should not have been crushed, such as enteric-coated and extended-release tablets, were crushed and administered inappropriately. Staff interviews indicated that agency nurses often lacked access to the automated medication contingency machine, further contributing to missed doses. There were also instances where staff did not know how to enter new physician orders into the electronic medical record, resulting in delays or omissions in care. In one case, a resident with cancer did not receive their prescribed Imatinib because the medication was delivered to their home instead of the facility, and the facility did not have a process in place to ensure the medication was available for administration by licensed staff. The resident ended up self-administering the medication brought from home, without proper assessment or documentation that they were capable of self-administration. Another resident experienced a delay in starting intravenous antibiotics after hospital readmission due to missing pharmacy orders and lack of timely follow-up by staff. These failures were confirmed through interviews with nursing staff, the DON, and the pharmacist, as well as review of medical records and facility policies.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, as evidenced by the omission or delay of necessary ordered medications. One resident with a diagnosis of myeloid leukemia did not receive the prescribed Imatinib 400mg tablet daily for a period of 14 administrations, due to the medication being delivered to the resident's home instead of the facility and subsequent issues with insurance coverage and pharmacy supply. Despite the resident's son bringing the medication from home and the resident self-administering, there was no documentation that the resident was assessed or authorized to self-administer this medication, nor was there evidence that the physician was aware of this arrangement. Additionally, some doses were incorrectly documented as administered when the medication was not available in the facility. Another resident, who returned from the hospital with an order for IV ertapenem to treat a urinary tract infection with acute encephalopathy, experienced a delay in receiving the antibiotic. The medication was not available for two days after the resident's return, with documentation discrepancies regarding the actual start date of administration. The delay was attributed to pharmacy issues, missing paperwork, and lack of timely communication between the facility, pharmacy, and hospital. The resident's medical record reflected inconsistent information about when the antibiotic therapy began, and the facility did not ensure the medication was available as ordered. A third resident with multiple chronic conditions, including acute and chronic respiratory failure and multiple myeloma, missed several scheduled morning doses of multiple medications due to leaving the facility for regular chemotherapy appointments before the medications were administered. The medications were not given at a different time, and there was no evidence that the physician was contacted to adjust the medication schedule to accommodate the resident's appointments. The facility's policy required medications to be administered within a specific time frame and for staff to document any deviations, but these procedures were not consistently followed.
Delay in Laboratory Result Causes Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure timely receipt and communication of a laboratory trough level result for a resident who was receiving intravenous vancomycin for acute osteomyelitis of both ankles and feet. The resident was admitted with an infected foot ulcer and had a physician's order for daily vancomycin infusions, which required a vancomycin trough level to be obtained and resulted before continuing the antibiotic therapy. The laboratory test was drawn as ordered, but there was a delay in receiving the results from the laboratory, which led to the resident missing four consecutive vancomycin infusions. Documentation in the Medication Administration Record and interdisciplinary notes indicated that the vancomycin doses were held each day due to the pending trough result, despite multiple follow-up calls to the laboratory by the DON. The laboratory reported being behind, and the result was not available until two days after the sample was collected. Both the DON and the attending physician confirmed their expectation that the result should have been available sooner, and the pharmacy also required the trough result before dispensing the medication. This delay in obtaining and communicating the laboratory result directly led to the interruption of the resident's prescribed antibiotic therapy.
High Medication Error Rate and Policy Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 32% error rate during the survey. Two residents were directly affected by these errors. Resident R6 received a Folic Acid supplement despite the order being discontinued on December 9, 2024. Additionally, five medications for R6 were administered more than 60 minutes after the scheduled time, which could potentially disrupt the prescribed administration intervals. Resident R7 was also affected by medication errors. The resident was observed receiving two sprays of Fluticasone Propionate in each nostril, contrary to the order of one spray per nostril. Furthermore, a blood pressure medication was administered more than an hour after the scheduled time, which could affect the medication's efficacy and the resident's health. The facility's policy on medication administration was found to be vague, lacking specific guidelines on the timing of medication administration. The Director of Nursing acknowledged the absence of a clear policy and stated that nurses are expected to administer medications within one hour before or after the scheduled time. However, the facility did not have a formal policy to guide nurses on this practice, contributing to the high medication error rate observed.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to provide adequate pain management for two residents, R16 and R44, as observed during a survey. R16 did not receive the prescribed topical pain relief medication as ordered by the physician, and there were incomplete pain assessments and evaluations of the effectiveness of pain interventions. Specifically, R16 was observed expressing pain and concern about upcoming physical therapy, yet the LPN did not conduct a comprehensive pain assessment, nor was the topical medication applied correctly. The medication was documented as administered, but it was applied to the back instead of the leg as ordered, and there was no documentation of pain levels or assessments before or after medication administration. R44 also experienced inadequate pain management, with incomplete pain assessments and evaluations of medication effectiveness. Despite receiving pain medications such as Robaxin and Hydrocodone, there was a lack of documentation regarding the numerical pain scale and re-evaluation of pain assessments. The surveyor noted discrepancies in the medication records, with more doses of Hydrocodone documented on the controlled drug receipt form than on the medication record, indicating a lack of proper documentation and monitoring of pain management. The facility's policy on pain assessment and management outlines the need for comprehensive pain evaluations and consistent monitoring, which were not adhered to in these cases. The surveyor's findings highlight a failure to follow the facility's pain management procedures, resulting in inadequate pain relief and documentation for the residents involved.
Medication Dispensing and Equipment Labeling Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing of medications for two residents, R44 and R369. For R44, there was a discrepancy between the Medication Administration Record (MAR) and the controlled medication narcotic count sheet. R44 was prescribed Hydrocodone 10/325 mg but was receiving Hydrocodone 5/325 mg instead, which did not provide adequate pain relief. This issue persisted from July 10, 2024, until it was corrected after R44 brought it to the staff's attention. Additionally, R44's MAR did not accurately reflect the administration of Protonix, which was supposed to be given 30 minutes before meals but was administered after meals instead. R44, who has diagnoses including Multiple Sclerosis and Gastro-Esophageal Reflux Disease (GERD), reported these discrepancies to the surveyor. The surveyor noted that the MARs provided by the facility showed inconsistencies in the administration of Hydrocodone, with some doses not administered on specific dates and others given in incorrect amounts. The Director of Nursing (DON) was unable to provide an explanation for the discrepancies between the MAR and the narcotic count sheet during the survey. For R369, the issue involved the labeling of personal medical equipment. The surveyor observed that R369's personal glucose monitor was not properly labeled with the resident's name, only with a room number, which was not R369's room number. This lack of proper identification could lead to potential errors in the use of medical equipment. The LPN responsible for medication administration confirmed the labeling practice but assured the surveyor that they knew which monitor belonged to R369.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care according to professional standards and the comprehensive person-centered care plan for two residents, R13 and R25. R13 was admitted with a left ankle fracture and surgical pin sites, requiring specific wound care as per hospital discharge instructions. However, the facility delayed the initiation of treatment for R13's left extremity and heel wound, starting two days after admission. The facility also did not follow the hospital's recommended treatment for pin sites, using betadine instead of the prescribed saline and hydrogen peroxide solution. Furthermore, there were significant gaps in the documentation of wound assessments for R13, with no assessments for the left heel after April 5, 2024, the left upper thigh after April 1, 2024, and no assessments for the left ankle pin site. R13 was eventually transferred to the hospital with severe sepsis. For R25, the facility failed to complete neurological checks following an unwitnessed fall, as per their policy. R25, who had multiple medical conditions including Type 1 Diabetes Mellitus and a history of kidney and pancreas transplants, experienced a fall on June 30, 2024. The facility's policy required neuro checks to be conducted for 72 hours following an unwitnessed fall, but the documentation was incomplete. Only two 15-minute and two 30-minute neuro checks were completed, instead of the required four each. Additionally, there were missing checks for July 1, 2024, and incomplete documentation for subsequent days. The deficiencies in care for both residents highlight a failure in adhering to established protocols and ensuring timely and appropriate treatment. The lack of proper documentation and follow-through on medical orders and assessments contributed to the inadequate care provided to R13 and R25, resulting in significant health risks for the residents involved.
Inadequate Supervision and Safety Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents, leading to multiple injuries. One resident, who was admitted with several diagnoses including dementia and anxiety disorder, sustained multiple injuries of unknown origin, including bruising to the eyes, a laceration requiring stitches, and fractures. The facility did not thoroughly investigate these injuries or assess potential safety concerns, such as the condition of the resident's Broda chair, which was missing caps and had sharp edges. Despite the resident's history of osteopenia, the facility did not implement adequate preventive measures to avoid further injuries. Another resident, with a history of significant fall risk, experienced an unwitnessed fall while attempting to reach a Gatorade. The facility's intervention was to provide a reacher, but the reacher was not consistently accessible to the resident, as observed by the surveyor over several days. Additionally, there was no documented RN assessment to rule out injuries after the fall, indicating a lack of proper follow-up and supervision. A third resident, who was non-weight bearing and required a Hoyer lift for transfers, was improperly transferred by a single CNA, resulting in a fall. The facility's investigation did not address why the CNA transferred the resident alone, nor did it ensure adherence to the care plan that required two-person assistance for transfers. These deficiencies highlight the facility's failure to provide adequate supervision and implement necessary safety measures to prevent accidents and injuries.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development and deterioration of pressure injuries. One resident, who was on hospice care, developed a stage 1 pressure ulcer on the coccyx, which was not assessed or treated by the facility's wound care doctor despite hospice's request. The resident's air mattress was incorrectly set for a much higher weight than the resident's actual weight, and no care plan revisions were made following the development of pressure areas. The facility also failed to document weekly skin checks and did not obtain physician orders for wound care treatments. Another resident was identified with an unstageable pressure injury on the left buttock, and the facility did not observe turning and repositioning as per the care plan. Treatments were not completed, and the care plan did not include approaches for repositioning until after the pressure injury was identified. The resident's pressure injury assessments showed a progression from unstageable to stage 3, with no evidence that the physician was notified of the pressure injury. A third resident had a deep tissue injury on the left heel, but the facility did not revise the care plan or implement treatment until two days later. During the survey, no heel boots were observed in place, and there was no assessment conducted on a specified date. The facility's failure to follow its own policy on pressure injury prevention and treatment, including timely assessments and care plan updates, contributed to the deficiencies identified by the surveyors.
Sanitation Deficiencies in Food Service and Dish Machine Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a sanitary manner, which had the potential to affect all 47 residents. During observations, a Food Service Associate (FSA) was seen preparing and serving food without wearing a beard net, despite having an evident beard. This was in violation of the facility's policy that requires all associates working with food to restrain facial hair with a beard net. The lack of adherence to this policy was confirmed by the Food Service Supervisor (FSS), who acknowledged that the FSA should have been wearing a beard net. Additionally, the facility's low temperature dish machines were not reaching the required minimum temperature of 120°F as per the facility's policy, and the manufacturer's guidelines indicated a minimum of 140°F. Observations showed that the dish machines on both the 2nd and 3rd floors consistently failed to reach these temperatures. Furthermore, the FSAs were not using test strips to verify the concentration of the sanitizer solution, which is necessary to ensure proper sanitation. The logs for dish machine temperatures and sanitizer concentrations were found to be incomplete and inaccurate, with repeated entries of 100 ppm for the chlorine rinse, suggesting a lack of proper monitoring and documentation. The surveyor noted that there was no managerial oversight, as evidenced by the absence of weekly review signatures on the dish machine logs. This lack of oversight contributed to the ongoing issues with dish machine temperatures and sanitizer testing. The facility's failure to adhere to its own policies and the manufacturer's guidelines for dish machine operation, along with the lack of proper food handling practices, constituted a significant deficiency in maintaining sanitary conditions for food service.
Inadequate Infection Control and Prevention Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during the survey. The Water Management Plan (WMP) was not updated to reflect changes in program members, did not include the Infection Preventionist (IP), and lacked revisions after the closure of a facility wing. Additionally, the WMP did not have a defined flush program for little-used outlets, logs to monitor water temperatures, or include eye washing stations and ice machines in its risk assessment. There was also a failure to measure and record residual disinfectant levels. The facility's surveillance of the infection control program was inadequate, lacking a defined policy for staff illness, a list of reportable communicable diseases, and a system for addressing increased infection rates. The facility's infection surveillance was found to be lacking, with no policy for staff illness procedures and no documentation of increased infection rates or interventions implemented. The surveillance data did not separate urinary tract infections (UTIs) into catheter-associated and non-catheter-associated infections. During interviews, it was revealed that the Director of Nursing (DON) and the Infection Preventionist (IP) were not adequately tracking or trending infection data, and there was no documentation of interventions for increased UTI rates. Additionally, the facility's response to a COVID outbreak was incomplete, with missing documentation of health department recommendations, restriction of admissions, and emergency meetings with the infection control committee. The facility also failed to adhere to proper infection control practices, as observed in the handling of personal protective equipment (PPE) and urinary catheter bags. Staff did not wear appropriate PPE when providing care to a resident on Enhanced Barrier Precautions, and hand hygiene was not consistently performed. Furthermore, a resident's urinary catheter bag was repeatedly observed on the floor, uncovered, and not handled hygienically by staff. These observations indicate a lack of adherence to the facility's policies and procedures for infection control, contributing to the overall deficiency in maintaining a safe environment for residents.
Failure to Complete and Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required 92 days for six residents. The surveyor identified that the MDS assessments for residents R27, R5, R44, R29, R25, and R50 were not completed and submitted on time. The delay was attributed to the facility's computer system being inaccessible from May 8, 2024, to June 24, 2024, during which the RN/MDS-G responsible for completing the assessments was not present at the facility. As a result, several MDS assessments were pending completion and submission. The surveyor's investigation revealed that the RN/MDS-G was working on completing the overdue MDS assessments, with a target completion date of July 31, 2024, coinciding with the transition to new facility ownership. The RN/MDS-G indicated that approximately 30 MDS assessments, mostly quarterly and discharges, were still pending. The surveyor noted that the facility's Emergency Preparedness plan did not include specific instructions for completing and submitting MDS assessments during electronic medical record (EMR) downtime. The surveyor reviewed the facility's EMR Disaster and Downtime Process, which outlined general procedures for handling unanticipated EMR downtime but lacked guidance on MDS completion. The surveyor confirmed that the MDS assessments for residents R25 and R29 were completed and submitted during the recertification survey. Despite the facility's submission of additional documentation, the concerns regarding the timely completion and submission of MDS assessments remained unresolved.
Failure to Act on Pharmacist Recommendations in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review and reported any irregularities to the attending physician, medical director, and director of nursing for five residents. The facility's policy requires that any irregularities noted during the medication regimen review (MRR) be reported and addressed promptly, with physician responses documented in the resident's medical record. However, the surveyor found that the MRRs for residents R5, R42, R25, R18, and R11 were either missing, not signed, or not acted upon by the physician. For resident R5, the surveyor was unable to locate pharmacist notes for several months, and the MRRs provided were not signed or dated by the physician. The MRRs contained recommendations for medication adjustments, such as adding a stop date for Lorazepam, but there was no evidence of physician response or action. Similarly, for resident R42, the MRRs recommended adding pantoprazole for gastroprotection and adjusting insulin orders, but these recommendations were not promptly acted upon by the physician. Residents R18 and R25 also had MRRs with recommendations for medication adjustments that were not reviewed or acted upon by the physician. For R18, the pharmacist recommended evaluating and potentially increasing the dosage of Sertraline, while for R25, the pharmacist suggested monitoring for involuntary movements and considering a dose reduction for Mirtazapine. Additionally, for resident R11, the surveyor noted that several months of pharmacy reviews were not signed or dated by the physician, indicating a lack of review and action on the pharmacist's recommendations.
Failure to Involve Resident in Care Planning Leads to Anxiety
Penalty
Summary
The facility failed to ensure that a resident, identified as R44, was given the opportunity to participate in the development and implementation of her person-centered care plan, particularly concerning her personal belongings. R44, who has diagnoses including multiple sclerosis, hypertension, anxiety, and blindness in the left eye, was assessed as having modified independence for cognitive skills and was independent with her activities of daily living. Despite this, the facility did not involve her in decisions regarding the handling of her personal items, leading to an incident where her belongings were removed from her room without her consent. The incident occurred when R44 was taken to the shower, and upon returning, she discovered that several personal items, including Styrofoam bowls, a robe, and two dollar bills, were missing. The resident expressed that she felt violated and anxious about staff entering her room without her knowledge. The facility's social worker acknowledged the incident and apologized to R44, but the care plan was not updated to address her anxiety and concerns about staff entering her room until after the surveyor's intervention. The surveyor's observations and interviews with staff and the resident revealed that R44 was not comfortable leaving her room due to fear of her belongings being taken. The facility's failure to involve R44 in her care planning and to respect her personal space contributed to her anxiety and reluctance to participate in activities outside her room. The deficiency was noted as the facility did not develop a care plan with R44's participation to address her concerns and reduce her anxiety about staff entering her room and handling her belongings.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident, identified as R29, to the State Survey Agency. R29, who was admitted with diagnoses including heart failure, dementia, and anxiety disorder, was noted to have multiple injuries over a period of time. On May 2, 2024, bruising was observed on R29's left eye and breast, and on May 16, 2024, additional bruising was noted on the right eye and foot, along with a laceration between the toes. Despite these injuries, which included a fractured toe and required stitches, the facility did not report them as required by their policy. The facility's policy mandates that all injuries of unknown origin be promptly reported to appropriate authorities. However, the facility's investigation concluded that the injuries were self-inflicted or due to equipment issues, such as a missing cap on a Broda chair. The Nursing Home Administrator (NHA) and Director of Nursing (DON) attributed the injuries to R29's combative behavior and osteoporosis, without sufficient evidence or documentation to support these claims. The facility's failure to report these injuries was highlighted during a surveyor's investigation, which noted the lack of documentation and reporting to the state agency. The surveyor's interviews and record reviews revealed that the facility did not adhere to its own policy of reporting injuries of unknown origin. Despite the presence of multiple injuries and the resident's inability to explain them, the facility did not submit the required reports to the state agency. The surveyor expressed concerns about the facility's handling of the situation, noting that the injuries met the definition of unknown origin and should have been reported accordingly.
Failure to Investigate Resident Injuries
Penalty
Summary
The facility failed to ensure that all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated. Specifically, the facility did not conduct a comprehensive investigation into the injuries of a resident, identified as R29, who was found with multiple bruises and fractures of unknown origin. The facility's policy required that all such incidents be promptly reported and thoroughly investigated, but this was not adhered to in the case of R29. R29, who was admitted with diagnoses including heart failure, dementia, and anxiety disorder, was noted to have bruising on multiple occasions, as well as a fractured toe and a laceration requiring stitches. Despite these injuries, the facility did not report them to the state survey agency or complete a thorough investigation. The facility's documentation was insufficient, with only one staff statement attributing the bruising to R29 holding a babydoll tightly, and no comprehensive investigation into the cause of the injuries was conducted. The facility's failure to investigate was further highlighted by the lack of documentation and reporting of the injuries to the state agency. The facility's explanations for the injuries, such as attributing them to self-infliction or the resident's osteoporosis, were not substantiated with thorough investigations or evidence. The surveyor noted that the facility did not provide documentation of resident interviews or signed staff statements, indicating a lack of compliance with their own policies and procedures for handling such incidents.
Failure to Notify HCPOA and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Power of Attorney (HCPOA) and primary physician of significant changes in the resident's condition and status. The resident, who was admitted with diagnoses including heart failure, dementia, and anxiety disorder, was receiving hospice care and had an activated HCPOA. Despite this, the facility did not inform the HCPOA or the primary physician about the resident's transfer to the emergency room for an x-ray, the development of a stage 1 pressure ulcer, or the non-administration of scheduled pain medications. The report highlights multiple instances where the facility did not adhere to its policy of notifying relevant parties about changes in the resident's condition. The resident experienced several injuries, including bruising and a laceration that required medical attention, yet there was no documentation of notification to the primary physician or HCPOA. Additionally, the resident's scheduled morphine doses were not administered on several occasions, and the primary physician was not consulted about this deviation from the prescribed treatment plan. The surveyor's findings indicate a lack of communication and documentation regarding the resident's care, which is contrary to the facility's policy. The facility's failure to notify the HCPOA and primary physician of significant changes, such as the development of a pressure ulcer and the resident's transfer to the emergency room, demonstrates a deficiency in the standard of care expected in such situations.
Failure to Complete Timely MDS Assessments Due to EMR Downtime
Penalty
Summary
The facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for two residents, R18 and R21, within the required regulatory timeframe. R18's annual MDS was due on May 15, 2024, but was not completed and submitted until July 18, 2024, during the recertification survey. Similarly, R21's annual MDS was due on May 8, 2024, but was not completed and submitted until July 15, 2024. This delay resulted in the absence of timely annual comprehensive assessments, which are necessary for reviewing and updating care plans based on the residents' current needs. The facility's failure to complete these assessments in a timely manner was attributed to a lack of access to electronic medical records (EMR) from May 8, 2024, to June 28, 2024, during which the MDS Registered Nurse (RN-G) was working at another facility. The surveyor's investigation revealed that the facility did not have a documented process for completing and submitting MDS assessments during EMR downtime. Although the facility had an EMR Disaster and Downtime Process, it did not include instructions for handling MDS assessments. The Nursing Home Administrator acknowledged that the MDS assessments should have been completed on paper during the downtime. The facility's failure to address this gap in their emergency preparedness plan contributed to the delay in completing the MDS assessments for R18 and R21, as well as approximately 30 other assessments from May and June.
Failure to Ensure Privacy and Dignity for Resident with Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and was provided dignity. The resident, who was admitted with a urostomy and a PICC line for antibiotic administration, was observed multiple times with their catheter bag visible from the hallway and not covered in a privacy bag. Despite the resident's intact cognition and ability to communicate, the care plan was not updated to reflect the resident's preference regarding the visibility of the catheter bag. The surveyor noted the presence of hematuria in the catheter bag during observations, which the resident attributed to a recent urostomy placement and ongoing antibiotic treatment for a major infection. The surveyor discussed the observations with the unit manager and the director of nursing, who acknowledged the concern. It was revealed that a family member of the resident preferred the catheter bag to remain uncovered for visibility. However, the facility did not revise the care plan to document the resident's own preference on this matter, which is a lapse in ensuring the resident's dignity and privacy. The facility's inaction in updating the care plan to reflect the resident's wishes led to the deficiency noted by the surveyor.
Deficiency in Respiratory Care for Resident
Penalty
Summary
The facility failed to ensure that necessary respiratory care services were consistent with professional standards of practice for a resident requiring continuous oxygen therapy. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia, was observed with unlabeled oxygen tubing and a dry humidification jar on multiple occasions. The facility's policy on oxygen administration requires that the humidifier bottle and oxygen tubing be labeled and dated, and that the water level in the humidifying jar be checked periodically to ensure it is sufficient. However, during the survey, the resident's oxygen tubing was not labeled, and the humidification jar was found to be dry and not dated, indicating a lapse in adherence to the facility's policy. The resident's treatment administration record indicated that the tubing and humidification were last changed several days prior to the survey, with the next change scheduled for a future date. Despite this schedule, the humidification jar was observed to be empty, and the tubing remained unlabeled. The unit manager acknowledged the concerns raised by the surveyor and confirmed that the night shift was typically responsible for changing the tubing and humidification. The nursing home administrator also acknowledged the surveyor's concerns, indicating an awareness of the deficiency in providing appropriate respiratory care for the resident.
Lack of Stop Date and Rationale for PRN Ativan Order
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary psychotropic medications, specifically Ativan, without a proper stop date or documented rationale for extending the PRN order beyond 14 days. The resident, who was admitted with multiple diagnoses including anxiety disorder and depression, had an order for Ativan 0.5 mg every eight hours as needed, but there was no stop date or physician's rationale documented for extending the PRN order. The facility's policy requires that any PRN psychotropic medication order extended beyond 14 days must have a documented rationale and specific duration indicated by the practitioner. During the survey, it was noted that the resident's Ativan order lacked a stop date, and the physician's progress notes did not address the continuation of the PRN Ativan. The RN/UM indicated that the hospice team was responsible for the medication orders, but there was no communication or documentation from the hospice team regarding the rationale for the extended use of Ativan. The surveyor informed the NHA and DON of the deficiency, highlighting the absence of a stop date and documented rationale for the PRN Ativan order.
Failure to Provide Routine Dental Care to Resident
Penalty
Summary
The facility failed to assist a resident, identified as R25, in obtaining routine dental care, which was necessary due to the resident's poor oral health condition. R25, who was admitted with multiple medical diagnoses including rhabdomyolysis, type 1 diabetes mellitus, and kidney and pancreas transplants, had a Brief Interview for Mental Status (BIMS) score indicating moderately impaired decision-making skills. Despite having only 4-5 blackened teeth and expressing a desire to see a dentist for potential denture fitting, R25 was not offered dental services since admission. The facility's policy requires that dental services be available and documented, but there was no care plan addressing R25's dental needs, and no record of R25 being on the dental list. Interviews with facility staff revealed a lack of communication and documentation regarding R25's need for dental services. The social worker and medical records personnel were unaware of R25's dental needs, and the admission coordinator confirmed that individual consents for dental services were not obtained. The nursing home administrator acknowledged the oversight, noting a change in leadership, but stated that dental services are typically offered within six months of admission. The deficiency was only addressed after the surveyor brought it to the facility's attention, highlighting a failure to adhere to the facility's policy and impacting R25's quality of life.
Failure to Provide Assistive Eating Equipment
Penalty
Summary
The facility failed to provide special assistive eating equipment for a resident, identified as R40, who required assistance due to medical conditions including Parkinson's Disease, weakness, protein-calorie malnutrition, and dysphagia. Despite being cognitively intact with a BIMS score of 15, R40 needed partial to moderate assistance with eating. The resident's nutrition risk assessment indicated a need for special utensils and cups, but these were not provided. Observations by the surveyor revealed that R40 struggled to eat independently due to shaky hands and was unable to use the standard metal utensils and foam cup with a straw provided. Interviews with facility staff, including a CNA, Unit Manager, Dietary Aide, and DON, highlighted a lack of awareness and communication regarding R40's need for special eating equipment. The CNA and Unit Manager acknowledged R40's need for assistance, particularly with meals requiring utensils. However, the dietary assessment note recommending special utensils was not seen by the DON until pointed out by the surveyor. The Speech Therapist, who had evaluated R40, confirmed the need for a mechanical soft diet initially, which was later upgraded. The deficiency was evident when R40's meal was left untouched due to the lack of appropriate assistive devices and assistance, as observed by the surveyor.
Deficiency in Hospice Service Coordination
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for two residents, R5 and R29, as identified during a survey. For R5, hospice visit notes were missing from both the medical record and the hospice binder located at the nurse's station. Despite having a hospice care plan in place, there was confusion among staff regarding the schedule and presence of hospice staff, as well as the identity of the hospice liaison. Interviews with various staff members, including registered nurses and the Director of Nursing, revealed a lack of awareness and communication about hospice visits and documentation. For R29, the facility did not complete the recertification of terminal illness, and there was no list of assigned hospice staff with contact information available. The hospice binder lacked a schedule of hospice staff visits, and the facility staff were unaware of a designated liaison for hospice communication. Interviews with hospice staff and facility nurses indicated that communication forms were not consistently placed in the hospice binder, leading to care issues not being addressed timely or at all. The facility's obligations under the Nursing Facility Services Agreement with the hospice provider were not met, as there was no designated liaison to coordinate care between the facility and hospice. The agreement required the facility to ensure comfort and care for hospice patients and to work with hospice to develop and maintain a care plan. However, the lack of communication and coordination between the facility and hospice staff resulted in deficiencies in the provision of hospice services for both residents.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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