Wood Aven Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Wausau, Wisconsin.
- Location
- 1821 N 4th Ave, Wausau, Wisconsin 54401
- CMS Provider Number
- 525503
- Inspections on file
- 20
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Wood Aven Health And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to provide transfer notices with a specific reason for transfer for multiple residents, including residents transferred for sepsis/cellulitis, UTI, hyperkalemia, COVID infection, and wound or fall-related hospitalizations. The notices used general language about urgent medical needs or welfare needs instead of the actual basis for transfer, and the Ombudsman notifications for several hospital transfers were delayed for weeks or months. The Social Services Manager stated notifications were usually sent monthly and could not recall why some were delayed.
Failure to Assess Clinical Appropriateness for Self-Administration of Medications: A resident with COPD, weakness, low back pain, and reduced mobility had inhalers and topical pain gel kept in the room and at bedside without an IDT self-administration assessment, physician order, or care plan entry supporting self-administration. Surveyors observed unlabeled and labeled inhalers and multiple tubes of Voltaren gel in the room; the resident gave inconsistent responses about using the inhalers, said he could not reach the meds on the windowsill, and stated CNAs applied the gel during cares. An LPN said the resident could use the inhalers but needed cueing, while the DON stated residents are assessed on admission and medications are not to be left in rooms.
Failure to notify the provider of a resident’s change in condition. A resident with intact cognition and diagnoses including CKD stage 3 had multiple SBP readings below the facility’s standing-order threshold, but no provider notification was documented. ST also documented visual hallucinations, yet there was no documentation that nursing was informed or that the provider was notified. RN, LPN, and DON interviews showed inconsistent understanding of when and how to report abnormal findings.
The facility failed to follow its abuse prevention policy requiring criminal background screening for employees. Record review showed that a CNA did not have updated DOJ and IBIS results on file before starting work, and HR could not provide DOJ or IBIS documentation for a facility driver. Interviews confirmed the missing background information for both employees.
A resident with intact cognition, bilateral upper extremity impairment, and increasing weakness had changing transfer needs documented by therapy, including use of a Hoyer lift when weakness was noted. However, staff continued using an EZ-Stand for transfers, causing bruising and pain, and the resident later fell when her knees gave out during a toilet transfer. The resident’s care plan was not updated with the new transfer status until after the incident, and staff were confused about the difference between transfer devices.
A resident admitted after fractures and a pelvic hematoma had conflicting bladder status documentation, with nursing notes showing continence while CNA tasks showed daily urinary incontinence. Although the resident had prior independence with toileting and the facility policy required an admission bowel and bladder evaluation to guide an individualized toileting program, no bladder care plan, goals, or interventions were developed, and staff were observed not offering or assisting with toileting.
A facility did not ensure appropriate care for two residents with PEG tubes. The facility’s policy allowed tube placement checks by auscultation, and staff used the “whoosh” or “swish” method for tube verification even though it was not a nationally recognized standard of practice. For one resident with dysphagia and aspiration pneumonia, an LPN verified PEG placement by listening for air through a stethoscope before giving meds. For another resident with dysphagia, ALS, and prior aspiration-related illness, an LPN also used auscultation to check placement and did not complete the ordered gastric residual check.
Medication Administration Error with PEG-Tube Bowel Regimen: An LPN did not administer a resident’s ordered Metamucil bowel regimen correctly through a PEG tube. The resident, who had dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia/hemiparesis after cerebral infarction, was ordered Metamucil mixed with 4 to 8 oz of water, but the LPN used only 30 cc, did not stir the medication, and discarded most of the clumped dose. The LPN stated he was unaware of the water requirement and had not been giving extra water as ordered.
The facility did not maintain an infection prevention program for several residents. Staff did not implement EBP for two residents with open wounds, including one with a facility-acquired pressure injury and another with an infected port-a-cath site; both rooms lacked EBP signage and PPE availability as observed by surveyors. In another instance, an RN did not perform hand hygiene during a medication pass while handling the med cart, laptop, narcotic book, stock meds, and assisting a resident with medications.
A resident admitted with nerve pain and spinal stenosis did not receive scheduled doses of Lyrica for pain management due to medication unavailability and delays in pharmacy delivery. Staff documented the issue and attempted to notify the pharmacy and charge nurse, but the medication was not administered for several scheduled doses. The DON was not informed of the missed doses, and the facility lacked a written policy for acquiring medications when not available.
A resident reported feeling degraded by a CNA's comment about his odor, which was not thoroughly investigated by the facility. The investigation did not include interviews with all nursing staff on duty, as required by policy, leading to an incomplete assessment of the mistreatment allegation.
A resident with a history of opiate use and constipation was hospitalized due to fecal impaction after the facility failed to follow its bowel protocol. Despite the resident's complaints of severe pain and a history of fecal impaction, staff did not perform a thorough GI assessment or document interventions. The resident had to call 911 for assistance, highlighting a significant lapse in care.
A dietary aide at a facility was observed not allowing clean dishes sufficient time to air dry before stacking them, leading to standing water in dishes and potential contamination. The dietary supervisor acknowledged the risk and the need for changes in dishwashing practices.
A facility failed to monitor and adjust psychotropic medication dosages for a resident, identified as R19, who was on antipsychotic, antianxiety, and antidepressant medications. Despite the facility's policy requiring gradual dose reductions (GDR) and the absence of documented behavioral concerns, no GDR was attempted. The resident's care plan aimed for the lowest effective dose, but the physician increased the medication dosage without clinical rationale. Observations and staff interviews indicated no behavioral issues, and the facility acknowledged the need for improved monitoring processes.
Incomplete Transfer Notices and Delayed Ombudsman Notifications
Penalty
Summary
The facility did not ensure that residents or their representatives received transfer notices that included a specific reason for the transfer, and it did not consistently notify the Ombudsman of hospital transfers. Survey review found that for 4 of 5 residents identified in the report, the written transfer/discharge notices stated only that the transfer was necessary for the resident’s welfare or urgent medical needs, but did not document the specific reason the resident was being transferred. The facility policies reviewed required the transfer notice to include the specific reason and basis for transfer, and required physician documentation of the specific resident need that could not be met in the facility. For R8, the resident was admitted, transferred to the hospital, and later readmitted with sepsis and cellulitis, but the transfer notice dated 10/31/25 did not include a specific reason. A later transfer notice dated 11/24/25 also stated only that an immediate transfer was required by urgent medical needs, without a specific reason. The Social Services Manager’s email notifications showed that the Ombudsman was notified of the October hospitalization on 12/16/25, and the manager stated that notifications were usually sent around the 10th of each month after records were cleared up. For R67, the resident was transferred to the hospital and readmitted with UTI and hyperkalemia, and later transferred again for status post COVID infection. Both transfer notices dated 01/13/26 and 02/27/26 lacked a specific reason for transfer. The Ombudsman was notified of the January hospitalization on 03/27/26, and the Social Services Manager could not recall why it was delayed. For R19, the resident had multiple hospital transfers for worsening surgical incision wound, a fall, and later another hospitalization; one transfer had no written notice documented, and the other notices did not include the specific reason for transfer. The Ombudsman notifications for these transfers were delayed or sent months later. For R1, the resident was transferred by ambulance to the hospital for treatment of UTI, and the written notice of transfer did not include the specific reason for transfer.
Failure to Assess Clinical Appropriateness for Self-Administration of Medications
Penalty
Summary
The facility did not determine whether one resident was clinically appropriate to self-administer medications, specifically prescription topical creams and inhalers kept in the resident’s room and at bedside. The resident had diagnoses including COPD, muscle weakness, low back pain, and reduced mobility, and the MDS assessment indicated a BIMS score of 13 and that the resident made his own health care decisions. However, the care plan did not include any information related to self-administration of medications, and there was no physician order for self-administration or for medications to be stored at bedside or in the room. There was also no evidence that an interdisciplinary self-administration assessment had been completed to determine whether the resident could safely self-administer or store medications in the room. During observation, surveyors found four partially used tubes of Voltaren gel on the windowsill, an Advair inhaler on the windowsill without a pharmacy label, and a Spiriva inhaler on a tray table next to the bed with a pharmacy label. The resident stated he used the Spiriva inhaler when having breathing difficulty and said he could not reach the medications on the windowsill. He also stated he was not aware of the Voltaren gel on the windowsill and could not remember whether staff had applied it that day. The resident said CNAs applied the gel during cares because he was unable to reach the buttock area. Later, the resident could not recall whether inhalers had been administered by staff or himself. An LPN stated the resident could self-administer the inhalers but required cueing from staff, and the DON stated residents are assessed upon admission for self-administration and that no medications are to be left in a resident’s room.
Failure to Notify Provider of Low Blood Pressure and Mental Status Change
Penalty
Summary
The facility failed to notify the provider of changes in condition for one resident, R19, despite standing orders requiring provider notification for systolic blood pressure less than 90 or greater than 200. R19 was admitted with diagnoses including cognitive communication deficit, acquired absence of the right leg above knee, and chronic kidney disease stage 3, and the most recent quarterly MDS dated 03/18/26 documented a BIMS score of 15, indicating cognition intact. Surveyor review of vital signs showed multiple low blood pressure readings without documented provider notification, including 83/50 on 10/24/25, 87/56 on 10/25/25, 83/54 on 11/07/25, 89/61 on 11/17/25, and 84/53 on 02/25/26. Surveyor review of progress notes also showed that on 10/27/25 at 1:48 PM, ST documented that R19 reported recent visual hallucinations of seeing animals and spiders in the room, but there was no additional documentation that nursing staff were informed of the change in mental status and no documentation that the provider was notified. During interviews on 04/01/26, RN E stated that other staff such as ST would typically tell the nurse, who would then notify the provider and document it in a progress note. LPN D stated nursing would review the chart and decide whether to report abnormal blood pressure, and DON B stated nursing staff were expected to follow the standing orders and that the low blood pressures should have been reported to the provider.
Missing Background Screening Documentation for Two Employees
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not implement its abuse screening policy for 2 of 8 employees reviewed. The facility’s policy titled "Abuse Prevention" states that all employees will be properly screened for criminal background, but the record review showed that Certified Nursing Assistant P did not have Department of Justice (DOJ) and Integrated Background Information System (IBIS) results on file from the background check completed before starting work on 11/01/24. Instead, the facility only had DOJ and IBIS results from a prior background check dated 10/07/21. During interview, the Regional Human Resource K stated that when the company took over the prior year, a third-party company re-ran all employees’ backgrounds to start fresh, but the updated DOJ and IBIS for CNA P were missing. In a separate interview, the Human Resource Manager L stated that the facility was not able to provide a DOJ or IBIS for Facility Driver O, and the surveyor could not locate those reviews in the record.
Improper Transfer Equipment Used After Change in Transfer Status
Penalty
Summary
The facility did not ensure that the resident’s environment remained as free of accident hazards as possible when staff used the wrong transfer equipment for a resident whose transfer status had changed. The resident was admitted with multiple diagnoses including encephalopathy, UTI, cellulitis, tendon rupture of the right upper arm, polymyalgia rheumatica, peripheral venous insufficiency, GERD, atrial fibrillation, hypertension, and CKD. The resident’s MDS showed intact cognition with a BIMS score of 15/15, but also documented bilateral upper extremity impairment and need for substantial to maximal assistance with transfers. The resident’s care plan reflected extensive assistance for transfers, and later notes showed increasing difficulty with transfers, bruising, and staff concern that the resident was not standing well. Nursing documented bruising to the right lower abdomen and reported that the resident leaned heavily into a toilet paper dispenser when getting off the toilet. Therapy was requested because of worsening transfer ability, and OT later evaluated the resident and documented changing transfer guidance as weakness continued. OT notes indicated that if weakness was noted, a Hoyer lift should be used, and later documentation changed the resident to Hoyer lift status. Despite these changes, staff continued using an EZ-Stand mechanical lift for transfers. Nursing documented that the resident complained of arm pain and believed the bruising came from the machine used to lift her. On 03/29/26, staff were transferring the resident to the toilet when her knees gave out and she was helped to the floor. Surveyor review showed the resident’s care plan was not updated with the transfer changes until 03/31/26, even though therapy had recommended different transfer methods earlier. Interviews with OT, CNA, and the DON confirmed confusion among staff about the difference between transfer devices and that the resident should have been transferred with a Hoyer lift rather than the EZ-Stand.
Failure to Assess and Support Bladder Continence
Penalty
Summary
The facility did not ensure appropriate bowel and bladder assessment and toileting support for a resident who was continent of bladder on admission. R54 was admitted after a fall with a displaced fracture of the left humerus, pubis and hip socket, and a pelvic hematoma involving the urinary bladder. The resident’s records showed a BIMS score of 11/15, prior independence with toilet use and other activities of daily living, and an admission MDS indicating dependence for toileting hygiene, lower body dressing, transfers, wheelchair use, frequent urinary incontinence, and no toileting program attempted. Although the facility policy required bowel and bladder evaluation on admission to determine the appropriate program, the resident’s bowel and bladder evaluation completed on 02/28/26 identified the resident as continent or a good candidate, and no bladder care plan, goals, or interventions were developed. Daily skilled nursing notes from 02/25/26 through 04/01/26 documented the resident as continent of bladder and denying urinary complaints, while CNA task documentation for the same period indicated the resident was incontinent of bladder every day. During interview, the resident stated they now wore a diaper at times, used a urinal, or put on the call light, but staff were busy and the resident did not like to bother them. Surveyor observation showed the resident did not request toileting and staff did not offer or assist with toileting during the observed period. The DON stated the resident had been incontinent in the hospital due to the bladder being shifted from the hematoma, but based on nursing documentation was considered continent on admission, and further assessment, monitoring, or a toileting plan was not developed.
PEG Tube Placement Checks Used Auscultation and Missed Ordered Residual Monitoring
Penalty
Summary
The facility did not ensure that residents receiving enteral feedings were provided appropriate treatment and services to prevent complications for 2 residents with PEG tubes. The facility’s gastrostomy tube care policy allowed verification of tube placement by air auscultation, aspiration of gastric contents, X-ray, or external graduation marks, and staff were unable to identify a nationally recognized standard of practice used to develop the policy. The report states that auscultation is no longer a recommended process for checking tube placement. R10 was admitted with dysphagia and later had a PEG tube inserted after a failed swallow study and aspiration pneumonia. Physician orders directed staff to check gastric residual volume every 8 hours and to check tube placement by auscultation before initiating enteral feeding every shift. During observation, an LPN prepared to administer medications through R10’s PEG tube by gathering a stethoscope and syringe, then placed the stethoscope on the abdomen and pushed air into the tube to listen for a “whooshing” sound. The LPN stated that this was how tube placement was verified, and the DON stated the facility used auscultation and residual volume checks for PEG tube assessment. R55 was admitted with dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia and hemiparesis following cerebral infarction. The care plan and physician orders directed staff to check tube placement by auscultation before enteral feeding and to check gastric residual volume every 8 hours and as needed. During observation, an LPN administered medications through R55’s PEG tube, used a stethoscope and syringe to push air into the tube, and stated, “That sounds good, I heard a swish sound.” The surveyor noted that the LPN did not check gastric residual during the process, and the LPN later stated that he did not check residual as ordered.
Medication Administration Error with PEG-Tube Bowel Regimen
Penalty
Summary
The facility did not ensure that a resident was free from significant medication errors when the resident did not receive bowel regimen medication as ordered. The resident was admitted with dysphagia, ALS, pneumonitis due to inhalation of food and vomit, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The physician order dated 03/24/2026 directed Metamucil oral powder 48.57% (Psyllium), 1 tablespoon via PEG tube one time a day for loose stools, mixed in 4 to 8 ounces of free water. The resident’s record showed the last documented bowel movement on 3/28/26 at 7:45 PM as a small formed soft/normal stool. During observation on 03/31/2026, an LPN prepared the Metamucil by placing 1 tablespoon into a 30 cc medication cup and adding 5 cc of water without stirring. The LPN then administered medications through the PEG tube using a 60 cc syringe and gravity-fed 5 cc of water alternating each medication followed by 5 cc of water. The LPN stated the Metamucil was not the right choice for the resident and that it clumps in the cup and tubing. The LPN used only 30 cc of water, which was a quarter of the minimum ordered amount, was unable to administer the full dose, and discarded the majority of the clumped medication in the trash. Record review showed the LPN had administered the medication on four additional dates, and the LPN later stated he was not aware of the order to mix the medication with 4 to 8 ounces of water and had not been administering extra water per the order. Later that day, nursing notes documented that the resident had not had a bowel movement for 3 days and PRN MiraLAX was administered.
Infection Prevention Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent transmission of communicable disease and infection for 3 of 17 sampled residents. For one resident with a facility-acquired stage II pressure injury to the buttock, staff did not initiate enhanced barrier precautions despite the resident having an open wound. The resident’s care plan did not include EBP focus or interventions, no standing orders for EBP were in place, and surveyors did not observe EBP signage outside the room during multiple observations. A CNA assisted the resident into bed with a mechanical stand device without PPE, and a red bag garbage container was observed in the room with gowns and gloves stored inside the doorway rather than with signage or a PPE cart outside the room. A second resident had a port-a-cath in the right anterior chest and later developed a boil/pustule over the port site that was cultured and treated with antibiotics; culture results identified methicillin susceptible Staphylococcus aureus, and the port remained visible through an open wound. This resident’s care plan also lacked EBP focus or interventions, no standing orders for EBP were in place, and surveyors did not observe EBP signage or PPE available in the room. In a third example, during medication administration to another resident, an RN handled the medication cart, laptop, narcotic book, stock medication bottles, and medication cards, then administered medications and assisted the resident with water without observed hand hygiene at any point during the pass. The RN later used hand sanitizer when questioned, and the infection preventionist stated hand hygiene should be performed before preparing medications and before assisting a resident with taking medications.
Failure to Administer Scheduled Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to administer scheduled medications as ordered for one resident who was admitted with diagnoses of radiculopathy and cervical spinal stenosis. Upon admission, an order was entered for the resident to receive Lyrica 25 mg, two capsules by mouth twice daily for pain management. However, the medication was not administered as scheduled for at least two days following admission, as documented in the Medication Administration Record (MAR) and confirmed by nurse notes indicating the medication was unavailable or pending from the pharmacy. Multiple staff members, including medication aides and nurses, documented the unavailability of the medication and reported attempts to notify the pharmacy and the charge nurse. The resident reported increased pain due to not receiving the prescribed medication and communicated this to a family member. The family member also inquired about the missed doses and was informed by staff that the facility had not received the order from the transferring facility on the day of admission. Documentation and interviews revealed that the pharmacy was contacted, but there were delays in response and delivery, and the resident did not receive the medication for several scheduled doses. Further review showed that the facility did not have a written policy outlining the process for acquiring medications when not immediately available. The Director of Nursing was not notified of the missed doses and stated that she would have intervened had she been aware. The facility's policy required nurses to reorder and ensure an adequate supply of medications, but this process was not effectively followed, resulting in the resident missing multiple doses of a routine pain medication.
Incomplete Investigation of Resident Mistreatment Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of mistreatment involving a resident, identified as R3, who was reportedly subjected to derogatory comments by a Certified Nursing Assistant (CNA C). The incident involved CNA C making a comment about R3's odor, suggesting he needed a bath because he smelled like he came out of a barn. R3, a former Social Services Director, found the comment degrading and felt bullied by CNA C's overall disrespectful behavior. The facility's investigation was incomplete as it did not include interviews with all nursing staff working in R3's rehabilitation unit during the time of the incident, as required by the facility's policy. The investigation conducted by the facility included interviews with 12 residents and two staff members, CNA C and CNA D, but failed to interview the remaining nine nursing staff members who were on duty during the relevant period. The Nursing Home Administrator (NHA) acknowledged the oversight and admitted to not having proof of speaking with other staff members. The facility's policy mandates that all staff having contact with the resident and the accused employee should be interviewed to ensure a comprehensive investigation. The deficiency was identified due to the lack of adherence to this policy, resulting in an incomplete investigation of the mistreatment allegation.
Failure to Follow Bowel Protocol Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R321, who has a history of daily opiate use and constipation. The facility's bowel protocol was not followed, and a thorough gastrointestinal (GI) assessment was not completed, leading to actual harm. R321 was hospitalized with severe pain and a fecal impaction after the facility staff did not adequately address his constipation, despite his history and symptoms. R321, who is cognitively intact and dependent on toileting and transfers, reported intense rectal pain to an LPN, who then contacted the charge nurse. However, the charge nurse instructed the LPN to observe R321 for the afternoon instead of taking immediate action. R321, experiencing unbearable pain, requested to be sent to the hospital, but when this did not happen, he called 911 himself. The medical record showed no documentation of abdominal pain prior to the incident, and the facility staff failed to check when R321 last had a bowel movement. The facility's records indicated that R321 had not had a bowel movement for four days, and despite an enema being administered, there was no documentation of its results or notification to the provider. The facility's Director of Nursing acknowledged that the bowel protocol was not followed, and there was no evidence of interventions being performed for R321's constipation prior to his hospitalization. This lack of adherence to the bowel protocol and inadequate response to R321's symptoms resulted in his hospitalization for fecal impaction.
Deficiency in Dishwashing Practices
Penalty
Summary
The facility was found to have a deficiency in its dishwashing and ware washing practices, which had the potential to affect all 76 residents. During an observation, a surveyor noted that a dietary aide, identified as DA C, was not allowing clean dishes sufficient time to air dry before stacking them. The dishes, including coffee cups and bowls, were observed to have standing water in them, indicating they were not completely air dried. Additionally, the bowls were not inverted during storage, which could lead to contamination from airborne particles and dust. The dietary aide, who had been in her position for several years, confirmed that the observed process of washing dishes and immediately stacking them was her usual practice. The surveyor also discussed the issue with the dietary supervisor, DS D, who acknowledged that the current dishwashing process could pose a risk for contamination. The supervisor recognized the need to change the manner in which dishes were stacked and to allow more time for air drying to prevent potential contamination.
Failure to Monitor and Adjust Psychotropic Medication Dosages
Penalty
Summary
The facility failed to effectively monitor psychotropic medications to ensure residents are receiving the lowest possible effective dose, as evidenced by the case of a resident identified as R19. The facility's policy on psychoactive medications mandates that such medications should only be administered when required to treat medical symptoms, with a focus on gradual dose reductions (GDR) to find the optimal dose. However, R19's records indicated that no GDR had been attempted despite the resident being on antipsychotic, antianxiety, and antidepressant medications. The resident's care plan included a goal to prescribe the lowest effective dose of medication, but this was not achieved. R19's medical history includes diagnoses of unspecified dementia with behavioral disturbance, anxiety, and dysthymic disorder. Despite these diagnoses, the resident's records showed no mood or behavioral symptoms, and no targeted behavioral concerns were documented. The facility's consultant pharmacist recommended a GDR for R19's antipsychotic medication, Rexulti, but the physician's response was inconsistent, with an increase in dosage noted without documented clinical rationale based on targeted behaviors. Observations and interviews with staff indicated that R19 did not exhibit behavioral or mood concerns, and the resident's routine was maintained without issues. The facility's Director of Nursing (DON) acknowledged that there was no clinical rationale for increasing R19's medication based on targeted behaviors, and the facility's process for monitoring residents on psychoactive medications needed improvement. The facility had not yet implemented a process improvement plan since its acquisition in November 2024. The lack of a structured process for monitoring and adjusting psychotropic medication dosages contributed to the deficiency identified by the surveyor.
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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