Whispering Pines Nursing And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ripon, Wisconsin.
- Location
- 50 Wolverton Ave, Ripon, Wisconsin 54971
- CMS Provider Number
- 525551
- Inspections on file
- 19
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Whispering Pines Nursing And Rehab, Llc during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, multiple medical conditions, and a Wanderguard bracelet for known wandering risk exited through an unalarmed, coded employees-only door after apparently observing staff enter the code. Night shift CNAs last saw the resident in the early morning hours but did not detect the absence until a therapist went to the room and found the resident missing, by which time the resident had already left the building. The resident traveled over a mile to a former apartment, where police later found the resident in bed, with the wheelchair and a foot pedal located on a stairwell. After return and subsequent evaluation, the resident was found to have sustained a fractured finger, which the resident reported occurred while slipping on the stairs en route to the apartment.
The facility failed to follow its abuse reporting policy and federal requirements by not reporting resident-to-resident sexual contact incidents to the State Agency and, in one case, not to local law enforcement. In one event, a cognitively impaired resident inappropriately touched a cognitively intact resident’s vaginal area and made an “I love you” comment, which was documented by nursing staff but not reported to the SA or police. In another event, the same cognitively impaired resident grabbed another cognitively intact resident by the shoulders and kissed them on the mouth in the dining room; although the resident later minimized the incident, they later told surveyors they did not want or expect the kiss and felt the other resident was sometimes stalking them. Despite a written policy requiring reporting of sexual abuse allegations to both the SA and police, leadership stated they did not report these incidents because the involved residents said they were not affected and were their own decision makers.
The facility failed to notify the Ombudsman of transfers and discharges for five residents, including those with CHF, sepsis, and other medical conditions. Notifications were sent months late, and the facility lacked proof of timely communication.
A resident reported a staff member stole their soda, but the facility failed to report the allegation of misappropriation to the State Agency or law enforcement. Despite discussions among the ADON, DON, and NHA, no documentation or reporting occurred, violating federal requirements.
A resident with moderate cognitive impairment reported that a staff member stole soda from their personal supply. The facility's ADON, DON, and NHA discussed the allegation but did not find it credible and failed to conduct a thorough investigation. Documentation related to the allegation was not provided, and an investigation was only initiated after surveyor inquiry.
A resident with a right below-the-knee amputation did not receive proper wound care as the dressing was not changed per physician's orders, and a weekly wound assessment was not conducted. The LPN confirmed the dressing was not changed due to the resident's absence for dialysis, and the ADON acknowledged the lack of a timely wound assessment.
The facility failed to maintain an effective infection control program, as staff did not use appropriate PPE for two residents on contact and enhanced barrier precautions. A resident with chronic C. diff infection was observed with staff entering the room without PPE, and another resident on enhanced barrier precautions was assisted with high-contact activities without gowns. Interviews revealed a lack of adherence to infection control policies, highlighting significant gaps in PPE usage.
Unalarmed Employees-Only Exit Allows High-Risk Resident Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident at high risk for wandering and elopement. The facility had an Elopement Risk and Prevention policy requiring adequate supervision and assistive devices to prevent elopement, wandering, and unsafe exits. The resident, who had diagnoses including rhabdomyolysis, acidosis, an automatic cardiac defibrillator, and alcoholic liver disease, had a BIMS score of 10/15 indicating moderately impaired cognition and an activated POA for healthcare. Due to wandering throughout the facility and difficulty finding the resident’s room, staff placed a Wanderguard bracelet on the resident in mid-March. On the date of the incident, the resident exited the facility between approximately 4:00 AM and 4:30 AM through an employees-only door that required a code and was not alarmed. Night shift CNAs reported last seeing the resident between about 3:00 AM and 4:30 AM, either at the nurses’ station or in the resident’s room in a wheelchair facing the window, but the resident’s absence was not identified until the Therapy Director went to the room around 6:18 AM and found the resident missing. The resident later described leaving the room, traveling down the hallway, turning into another resident hallway, and exiting through the coded employees-only door, then going out an unalarmed exit door and through a courtyard to the front of the building. The Nursing Home Administrator believed the resident likely observed staff entering the door code and used it to exit. The resident traveled away from the facility and was reported to police around 4:30 AM as an elderly man in flannel pajama pants pushing a wheelchair near local cross streets and a business, though police did not locate him at that time. The resident ultimately reached a former apartment approximately 1.1 miles from the facility, where police later found the resident asleep in bed with the wheelchair under a stairwell and a foot pedal at the top of the stairs. The facility became aware of the resident’s location at about 6:40 AM. The resident was transported to the ER, where bloodwork was normal and no imaging was initially done due to lack of reported pain. The following day, during therapy, the resident reported numbness in the fingers progressing into the hand; an X-ray ordered by the physician revealed a fracture of the left ring finger, which the resident attributed to slipping on the stairs while going to the apartment.
Failure to Report Resident-to-Resident Sexual Abuse Allegations to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to follow its own abuse and neglect prevention policy and federal requirements for reporting reasonable suspicion of a crime, specifically related to resident-to-resident sexual contact. The facility’s policy, dated 11/2017, requires reporting allegations of abuse, neglect, misappropriation, or exploitation to the State Agency (SA) within 24 hours and contacting law enforcement when concerns are criminal in nature, including sexual abuse. The policy also states that for allegations or incidents of sexual abuse, the facility is to make a police report with the local police department in addition to the preliminary report to the state health department. Surveyors determined that these reporting requirements were not followed for multiple incidents involving three residents. One incident involved a resident with early onset Alzheimer’s disease and dementia with behavioral disturbance, who had a BIMS score of 6/15 indicating severely impaired cognition, and another resident with multiple sclerosis and intact cognition (BIMS 15/15). A progress note documented that, in the evening, the cognitively impaired resident approached the cognitively intact resident outside the dining room. An agency nurse observed the cognitively intact resident looking uncomfortable and saw the other resident quickly move a hand away, though the nurse did not see the exact area touched. When questioned, the cognitively intact resident confirmed being touched and pointed to the vaginal area, nodded yes when asked if that area was touched, and reported that the other resident said, “I love you.” The facility completed an internal investigation, but surveyors noted that the incident was not reported to the SA or to the local police department, despite the sexual nature of the allegation. Another incident involved the same cognitively impaired resident and a different resident with intact cognition (BIMS 15/15) who had diagnoses including acute cystitis, psychophysical visual disturbances, and major depressive disorder. A progress note indicated that during supper, the cognitively impaired resident grabbed the other resident by the shoulders and kissed them on the mouth; the resident stated it did not feel good but was not upset at that time. A later progress note documented that the resident described the event as a joke and reported having no problem with the other resident. However, in a subsequent phone interview with the surveyor, the resident stated they did not want to be kissed, did not ask to be kissed, and were not expecting it, and described feeling that the other resident was sometimes “stalking” them. The facility’s investigation showed that this potential allegation of abuse was not reported to the SA, although it was reported to the police in the context of another incident. During interviews, facility leadership stated they used a resident-to-resident altercation flowchart and did not report these incidents because the involved residents indicated they were not affected and were their own decision makers, leading to the failure to report in accordance with policy and section 1150B of the Act.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to ensure timely notification to the Ombudsman regarding the transfers and discharges of five residents. These residents included one who was discharged home after an exacerbation of congestive heart failure, another discharged following hospitalization for sepsis, and three others who were transferred to the hospital for various medical conditions such as a positive blood culture, evaluation of a foot wound, and other health issues. The facility did not notify the Ombudsman of these transfers and discharges at the time they occurred. The surveyor's review of the facility's records revealed that the notifications were only sent to the Ombudsman on January 13, 2025, well after the events took place. The Social Worker responsible for sending these notifications was on leave during the fall, and the Nursing Home Administrator was supposed to send them in their absence. However, there was no evidence that this was done. The Ombudsman confirmed receiving the notifications late and emphasized the importance of facilities maintaining proof of sent documents.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically misappropriation of property, as required by section 1150B of the Act. A resident, identified as R22, reported to staff that a staff member had stolen soda from their personal supply. Despite the report, the facility did not notify the State Agency or local law enforcement about the allegation of misappropriation. The facility's policy mandates that any suspicion of misappropriation must be reported immediately to the Administrator and then to the State Agency within 24 hours. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Nursing Home Administrator (NHA) confirmed that the allegation was discussed among them, but no documentation was provided to the surveyor, and the allegation was not reported to the appropriate authorities. R22, who had moderate cognitive impairment, had reported the missing soda to ADON-D, who did not find the report credible and failed to take further action. This inaction led to a deficiency in the facility's compliance with federal reporting requirements.
Failure to Investigate Allegation of Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident, identified as R22, who reported that a staff member stole soda from their personal supply. R22, who has moderate cognitive impairment and was admitted with diagnoses including depression and surgical wound complications, noticed the soda missing after returning from an activity. R22 reported the incident to the Assistant Director of Nursing (ADON), who informed the resident that the allegation was addressed with the accused staff. However, the ADON, along with the Nursing Home Administrator (NHA) and Director of Nursing (DON), did not find the report credible and did not conduct a thorough investigation. Interviews with the ADON, DON, and NHA revealed that they discussed the allegation but did not document any investigation or take further action because they did not believe the allegation was credible. The ADON and DON planned to monitor the resident's soda supply but did not provide any documentation related to the allegation. The NHA confirmed that an investigation was only initiated after the surveyor's inquiry, indicating a delay in addressing the resident's report of missing soda.
Failure to Provide Proper Wound Care for Resident with BKA
Penalty
Summary
The facility failed to provide proper surgical wound treatment for a resident with a right below-the-knee amputation (BKA). The resident's wound dressing was not changed according to the physician's order, which specified changes every other day. The Treatment Administration Record (TAR) indicated that the dressing change was not completed on one of the scheduled days. The Licensed Practical Nurse (LPN) on duty confirmed that the dressing was not changed because the resident was not present due to dialysis, and the task was not completed later in the day. Additionally, the facility did not conduct a weekly in-house wound assessment for the resident's surgical wound, as required by the facility's policy. The Assistant Director of Nursing (ADON), who is also the wound nurse, confirmed that no assessment had been completed since the resident's admission. The ADON acknowledged that an assessment should have been conducted within 24-48 hours of admission to establish a baseline for the wound, but this was not done.
Inadequate Infection Control Practices in PPE Usage
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) for two residents on contact and enhanced barrier precautions. Resident R283, who was on contact precautions due to chronic Clostridium difficile infection, was observed multiple times with staff entering the room without donning the appropriate PPE, such as gowns and gloves, despite clear signage indicating the need for such precautions. The Director of Therapy and other staff members were noted to have entered the room without PPE and failed to disinfect equipment after use, contrary to the facility's policy. Resident R131, who was on enhanced barrier precautions due to a right below-the-knee amputation and dependence on dialysis, was also subject to improper PPE use. Staff members assisting with high-contact activities, such as toileting, did not wear gowns as required by the facility's policy. Despite having received training, staff misunderstood the requirements for gown use during high-contact activities, leading to non-compliance with the enhanced barrier precautions. Interviews with the Assistant Director of Nursing revealed a lack of understanding and adherence to the facility's infection control policies. The ADON acknowledged that contact precautions were not being followed correctly for R283 and that high-contact activities for R131 required PPE, including gowns, which were not consistently used. This deficiency highlights a significant gap in the facility's infection control practices, particularly in the proper use of PPE to prevent the transmission of infections.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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