Deficiencies (last 3 years)
Deficiencies (over 3 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
335% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
May 29, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to refund a resident's prepaid fees within 30 days of discharge.
Findings
The facility failed to refund a resident's money within the required 30 days after discharge, resulting in a delay of 73 days before the refund was issued. The delay was attributed to issues with the facility's accounting systems and lack of a clear refund policy.
Complaint Details
The complaint involved a resident (R1) who was not refunded $3,254.00 within 30 days after discharge. The refund was delayed 73 days due to issues with two different pay systems. The refund was eventually issued after multiple contacts by the resident's family member.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to refund a resident's money within 30 days of discharge. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Refund amount: 3254
Days delayed: 73
Prepaid service dates: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Discussed refund policy and accounting system issues causing refund delay |
Inspection Report
Complaint Investigation
Deficiencies: 11
Mar 31, 2025
Visit Reason
The inspection was conducted due to multiple complaints and allegations involving resident care, abuse, neglect, and safety concerns at Edgerton Care Center, Inc.
Findings
The facility failed to ensure proper documentation of advance directives, timely reporting and investigation of abuse allegations, adequate pain management, appropriate use of restraints, proper food safety and temperature control, and fall prevention interventions. Multiple residents experienced neglect, abuse, and inadequate care, including physical abuse of a resident by agency staff, delayed hospital transfer for a resident with GI bleeding, and failure to follow care plans for fall prevention.
Complaint Details
The complaint investigation involved multiple residents with allegations of abuse, neglect, improper care, and safety concerns. Several incidents involved failure to report abuse timely, inadequate investigations, and failure to protect residents from harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Actual harm: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure a copy of a resident's advance directive was included in the medical record for 3 of 17 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to make prompt efforts to document, investigate, and resolve grievances for 2 of 17 residents reviewed for grievances. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from physical abuse by agency CNA and LPN, including holding resident's hands down causing bruising and skin tears. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident is free from physical restraints not required to treat medical symptoms; resident observed in power lift recliner with remote out of reach restricting movement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and neglect allegations to appropriate authorities for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to respond appropriately to all alleged violations; investigations were incomplete or not conducted for multiple abuse and neglect allegations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders and resident preferences; delayed hospital transfer for GI bleed, inadequate bowel assessments, and inadequate pain management during wound care. | Level of Harm - Actual harm |
| Failed to ensure food and drink were palatable and served at safe and appetizing temperatures; cold scrambled eggs, sausage links and milk served at unsafe temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision and accident prevention interventions for residents; resident observed improperly disposing cigarette materials and fall prevention interventions not consistently implemented. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform proper hand hygiene and glove changes during food service, risking cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with an indwelling catheter had physician orders specifying catheter size and replacement schedule. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for advance directives: 17
Residents reviewed for grievances: 17
Residents affected by physical abuse: 1
Residents reviewed for restraints: 2
Residents with abuse allegations not timely reported: 5
Residents with incomplete abuse investigations: 5
Residents reviewed for pain management: 2
Residents with falls: 1
Food temperature: 115.3
Food temperature: 91.6
Food temperature: 45.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding multiple findings including abuse reporting, restraint use, and fall prevention |
| DON B | Director of Nursing | Interviewed regarding abuse reporting, restraint use, fall prevention, and clinical assessments |
| CNA H | Certified Nursing Assistant | Witness and reporter of physical abuse incident involving resident R46 |
| LPN G | Licensed Practical Nurse | Accused staff in physical abuse incident involving resident R46 |
| CNA F | Certified Nursing Assistant | Accused staff in physical abuse incident involving resident R46 |
| DPT J | Director of Physical Therapy | Interviewed regarding abuse incident and resident safety |
| SW C | Social Worker | Grievance Officer interviewed regarding investigation of abuse allegations |
| LPN S | Licensed Practical Nurse | Observed providing wound care causing resident pain |
| ADON HH | Assistant Director of Nursing | Interviewed regarding wound care and pain management |
| DM E | Dietary Manager | Interviewed regarding food temperature and kitchen sanitation |
| RN W | Registered Nurse | Interviewed regarding GI bleed and emergency response |
| RN T | Registered Nurse | Interviewed regarding smoking supervision and resident safety |
| CNA M | Certified Nursing Assistant | Interviewed regarding resident concerns about cold food |
| CNA N | Certified Nursing Assistant | Interviewed regarding fall prevention interventions |
| LPN R | Licensed Practical Nurse | Interviewed regarding fall prevention interventions |
Inspection Report
Complaint Investigation
Deficiencies: 12
Mar 31, 2025
Visit Reason
The inspection was conducted due to multiple allegations and complaints involving resident care, abuse, neglect, and safety concerns at Edgerton Care Center, Inc.
Findings
The facility failed to ensure proper documentation of advance directives, timely and thorough investigation and reporting of abuse allegations, appropriate restraint use, adequate pain management, proper food safety and temperature control, and fall prevention interventions. Multiple residents experienced neglect, abuse, and inadequate care, including physical abuse of a resident by agency staff, delayed reporting of abuse, failure to follow care plans, and unsafe food handling practices.
Complaint Details
The complaint investigation involved multiple residents with allegations of abuse, neglect, and inadequate care. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Actual harm: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure a copy of a resident's advance directive was included in the medical record for 3 of 17 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to make prompt efforts to document, investigate, and resolve grievances for 2 of 17 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from physical abuse by agency CNA and LPN, including holding resident's hands down causing bruising and skin tears. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure each resident is free from physical restraints not required to treat medical symptoms; resident observed in power lift recliner with remote out of reach restricting movement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to respond appropriately to all alleged violations; investigations were incomplete or not conducted for multiple abuse and neglect allegations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and care according to orders and resident preferences; delayed hospital transfer for GI bleed, inadequate bowel and hydration monitoring, and inadequate pain management causing resident distress during wound care. | Level of Harm - Actual harm |
| Failed to ensure food and drink is palatable, attractive, and at a safe and appetizing temperature; residents reported cold food and test tray food temperatures were unsafe. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards; observed poor hand hygiene by kitchen staff, unclean kitchen equipment, and inadequate temperature monitoring of resident food storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe, appropriate pain management for a resident requiring such services; resident experienced pain during wound care without adequate intervention. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for residents with indwelling catheters; no physician order for catheter size or replacement schedule for resident with catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision to prevent accidents; fall prevention interventions were not consistently implemented for a resident with multiple falls; unsafe smoking practices observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for advance directives: 17
Residents reviewed for grievances: 17
Residents reviewed for abuse: 17
Residents reviewed for restraints: 2
Residents reviewed for abuse reporting: 5
Residents reviewed for abuse investigations: 6
Residents reviewed for pain management: 2
Residents reviewed for food temperature: 17
Test trays observed: 1
Residents reviewed for food safety: 45
Residents reviewed for catheter care: 1
Falls for resident R2: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding multiple findings including abuse reporting, restraint use, and fall interventions |
| DON B | Director of Nursing | Interviewed regarding abuse reporting, restraint use, pain management, fall interventions, and catheter care |
| CNA H | Certified Nursing Assistant | Witness and reporter of physical abuse incident involving resident R46 |
| CNA F | Certified Nursing Assistant - Agency | Accused of physical abuse of resident R46 |
| LPN G | Licensed Practical Nurse - Agency | Accused of physical abuse of resident R46 |
| DPT J | Director of Physical Therapy | Interviewed regarding abuse incident and resident safety |
| SW C | Social Worker / Grievance Officer | Interviewed regarding grievance investigations |
| RN W | Registered Nurse | Interviewed regarding GI bleed incident and pain management |
| LPN S | Licensed Practical Nurse | Observed providing wound care causing resident pain |
| ADON HH | Assistant Director of Nursing | Interviewed regarding pain management and wound care |
| DM E | Dietary Manager | Interviewed regarding food safety and kitchen hygiene |
| RN T | Registered Nurse | Interviewed regarding smoking safety and resident behavior |
| CNA M | Certified Nursing Assistant | Interviewed regarding resident complaints of cold food |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify a physician and family about an incident where a resident (R2) was struck in the eye during a transfer, and failure to ensure proper medication administration.
Findings
The facility failed to promptly notify the physician and family about an injury to resident R2's eye caused by an EZ stand strap during transfer, did not investigate the incident, and delayed physician notification until an eye appointment three days later. Additionally, the facility did not ensure accurate medication administration, with R2 missing several doses of prescribed eye drops due to backorders and staff errors in documentation.
Complaint Details
The complaint investigation found that the facility did not notify the physician immediately after the resident was hit in the eye on 5/13/24, with notification delayed until the eye appointment on 5/16/24. The resident requested hospital care multiple times but was not sent. The facility also failed to complete an incident report and did not notify the Director of Nursing timely. Medication errors were identified where prescribed eye drops were not administered on several dates due to backorders and staff confusion.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to immediately notify the resident's physician and family of an injury caused by the EZ stand strap hitting the resident's left eye. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate medication administration, resulting in missed doses of Tobramycin-dexamethasone and Maxitrol eye drops for resident R2. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dates medication not administered: 5
Medication administration frequency: 3
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Interviewed about the incident with R2 and the EZ stand transfer; admitted failure to notify physician and complete incident report. |
| DON B | Director of Nursing | Interviewed regarding awareness of the incident and medication errors; confirmed failures in notification and staff education. |
| ADON E | Assistant Director of Nursing | Provided emailed statement about medication order and pharmacy backorder issues. |
Inspection Report
Complaint Investigation
Deficiencies: 4
May 15, 2024
Visit Reason
The inspection was conducted due to a complaint alleging sexual abuse by a Certified Nursing Assistant (CNA D) towards resident R2, and to investigate the facility's response to abuse allegations and pressure ulcer care.
Findings
The facility failed to implement its abuse prevention policies by allowing CNA D to continue resident care after an abuse allegation, failed to timely report the abuse to authorities, and did not conduct a thorough investigation including skin checks for non-interviewable residents. Additionally, the facility failed to provide appropriate pressure ulcer care by not repositioning resident R1 as per care plan.
Complaint Details
The complaint involved an allegation by resident R2 that CNA D touched her breast on 4/20/24. The facility failed to remove CNA D from resident care immediately, allowed him to work independently on another floor, did not report the abuse timely to state authorities, and did not conduct a thorough investigation including skin checks for non-interviewable residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement policies and procedures to prevent abuse, neglect, and theft, including not removing CNA D from resident care after abuse allegation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse and neglect to proper authorities and protect residents during investigation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to alleged violations by not thoroughly investigating sexual abuse allegation, including lack of skin checks for non-interviewable residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers by not repositioning resident R1 every two to four hours as care planned. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 13
Residents affected: 3
Residents affected: 1
Dates and times not repositioned: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in sexual abuse allegation and failure to remove from resident care |
| RN E | Registered Nurse | Instructed CNA D to move floors but did not restrict resident care; interviewed by surveyors |
| ADON C | Assistant Director of Nursing | Reported abuse allegation and stated staff member should have been removed from resident care |
| DON B | Director of Nursing | Reported abuse allegation, contacted RN E and NHA A, acknowledged failure to restrict CNA D |
| NHA A | Nursing Home Administrator | Informed DON B about investigation and abuse policy not followed |
| CNA J | Certified Nursing Assistant | Aware of abuse allegation and reported to appropriate staff |
| SS I | Social Services | Assisted with abuse investigation and resident interviews |
| CNA F | Certified Nursing Assistant | Interviewed about repositioning documentation for resident R1 |
| CNA G | Certified Nursing Assistant | Interviewed about repositioning documentation for resident R1 |
| CNA H | Certified Nursing Assistant | Interviewed about repositioning expectations and documentation |
Inspection Report
Annual Inspection
Deficiencies: 8
Mar 28, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to resident rights, grievance resolution, abuse reporting, resident care including activities of daily living, food safety, infection control, and immunization policies.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and respect, inadequate grievance resolution, failure to timely report and investigate abuse allegations, insufficient assistance with activities of daily living such as bathing, improper food storage and sanitation practices, failure to implement effective infection prevention and control measures including COVID-19 outbreak identification and staff testing, and lack of proper policies and documentation for influenza vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity and respect, including staff not knocking before entering a resident's room and not explaining care procedures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure prompt resolution of grievances and proper documentation of grievances voiced by residents or their representatives. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or exploitation to proper authorities for multiple resident incidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate alleged violations involving abuse, neglect, exploitation, or mistreatment for certain resident-to-resident incidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled showers and adequate assistance with activities of daily living for residents unable to perform these tasks independently. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper thermometer use, staff food stored with resident food, undated/unmarked food, unclean equipment, and dented cans in circulation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish and implement an effective infection prevention and control program, including failure to identify a COVID-19 outbreak and failure to test or exclude symptomatic staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures ensuring residents and/or responsible parties receive education and documentation regarding influenza vaccination offers and declinations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity and respect deficiency: 17
Residents reviewed for grievance deficiency: 14
Residents reviewed for abuse investigations: 17
Residents reviewed for ADL assistance: 12
Residents affected by infection control deficiency: 71
Residents reviewed for influenza immunization: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN U | Licensed Practical Nurse | Named in dignity and respect deficiency for not knocking or explaining care |
| NHA A | Nursing Home Administrator | Interviewed regarding resident rights, grievance policy, abuse reporting, and infection control |
| Nurse Manager C | Nurse Manager and Infection Preventionist | Interviewed regarding infection control and COVID-19 testing policies |
| CNA F | Certified Nursing Assistant | Interviewed regarding resident-to-resident incidents and ADL assistance |
| LPN G | Licensed Practical Nurse | Interviewed regarding resident-to-resident incidents and ADL assistance |
| CNA H | Certified Nursing Assistant | Interviewed regarding resident-to-resident incidents and ADL assistance |
| DM K | Dietary Manager | Interviewed regarding food safety deficiencies |
| EDH E | Executive Director of Hospice | Interviewed regarding hospice care and shower documentation |
| NM C | Nurse Manager and Infection Preventionist | Interviewed regarding infection control and influenza vaccination |
| CNA P | Certified Nursing Assistant | Interviewed regarding food labeling and storage |
Inspection Report
Routine
Deficiencies: 9
Mar 28, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, grievance resolution, abuse reporting, pressure ulcer care, accident prevention, food safety, infection control, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate grievance resolution, failure to timely report and investigate abuse allegations, improper pressure ulcer care, inadequate supervision to prevent accidents, unsafe food handling practices, failure to implement effective infection control measures including COVID-19 outbreak management, and incomplete documentation and administration of influenza vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity and respect, including staff not knocking or explaining care to resident R347. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure prompt resolution of grievances for resident R47, including lack of follow-up and documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or theft and report investigation results for 4 of 5 abuse investigations reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to all alleged violations involving abuse, neglect, exploitation, or mistreatment for 2 of 5 abuse investigations reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 2 of 3 residents reviewed for pressure injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for supervision and accidents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including thermometer misuse, staff food stored with resident food, undated/unmarked food, dirty equipment, and dented cans. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including failure to identify a COVID-19 outbreak and failure to test or exclude symptomatic staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, including lack of documentation of education, consent, or declination for residents R37 and R41. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity and respect: 17
Residents reviewed for grievances: 14
Residents reviewed for abuse investigations: 17
Residents reviewed for pressure injuries: 17
Residents reviewed for supervision and accidents: 17
Residents in facility: 71
Residents reviewed for influenza immunizations: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN U | Licensed Practical Nurse | Named in dignity and respect deficiency for not knocking or explaining care to resident R347 |
| NHA A | Nursing Home Administrator | Interviewed regarding resident rights, grievance resolution, abuse reporting, and infection control |
| Nurse Manager C | Nurse Manager | Interviewed regarding grievance resolution, pressure ulcer care, abuse reporting, and infection control |
| CNA F | Certified Nursing Assistant | Interviewed regarding resident-to-resident incidents and reporting |
| LPN G | Licensed Practical Nurse | Interviewed regarding resident-to-resident incidents and reporting |
| CNA H | Certified Nursing Assistant | Interviewed regarding resident-to-resident incidents and reporting |
| SSD I | Social Service Director | Interviewed regarding resident-to-resident incidents and reporting |
| AD J | Activity Director | Interviewed regarding resident-to-resident incidents and reporting |
| Cook Q | Cook | Observed not allowing thermometer to air dry before use |
| DM K | Dietary Manager | Interviewed regarding food storage and safety deficiencies |
| DA R | Dietary Aide | Tested positive for COVID-19; failure to identify outbreak |
| Driver S | Driver | Symptomatic staff not tested or excluded for COVID-19 |
| Housekeeping T | Housekeeping | Symptomatic staff not tested or excluded for COVID-19 |
| NM C | Nurse Manager / Infection Preventionist | Interviewed regarding infection control and vaccination deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to transcribe physicians' orders for surgical wound care, resulting in staff not administering treatment as ordered for one resident.
Findings
The facility failed to ensure transcription of physician orders for surgical wound care for Resident #1, leading to incomplete wound treatment. Interviews and record reviews revealed that some physician orders were not entered into the electronic medical record, causing staff to miss providing certain treatments.
Complaint Details
The complaint investigation found that the facility did not follow all physician orders for Resident #1's surgical wound care. The orders were inconsistently transcribed into the Medication Administration Record (MAR) and electronic medical records, leading to missed treatments. The resident developed a bad infection attributed by the surgeon to hardware, and staff were unaware of some treatment orders due to transcription failures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to transcribe physicians' orders for surgical wound care, resulting in staff not administering treatment as ordered for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for wound care: 3
Resident admission date: Aug 16, 2023
Assessment Reference Date: Aug 21, 2023
Care Plan start date: Aug 28, 2023
Referral Form date: Aug 24, 2023
Medication Administration Record timeframe: Aug 1, 2023
Medication Administration Record timeframe: Oct 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Current DON who provided care to Resident #1 and acknowledged failure to follow transcription process. |
| Previous Director of Nursing B | Director of Nursing | Initialed After Visit Summary on 10/03/2023. |
| Licensed Practical Nurse L | LPN | Described process of receiving and entering orders after resident appointments. |
| Licensed Practical Nurse F | LPN | Described process of medical records staff preparing packets and nurses entering orders. |
| Licensed Practical Nurse P | LPN | Followed instructions on resident's MAR for wound treatment. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 14, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to permit a resident (R1) to return to the nursing home following hospitalization, and concerns about improper discharge procedures and resident rights violations.
Findings
The facility failed to allow R1 to return after hospitalization despite a signed bed hold and the resident's activated power of attorney's wishes. The facility discharged R1 without proper 30-day notice, did not honor the right to appeal, and cited behavioral concerns as reasons for refusal. The resident remains hospitalized as no alternative placement was found. The facility closed the 2nd floor, limiting options for a low-stimulation environment needed for R1, and refused to provide 1:1 supervision unless paid privately. The facility acknowledged the inability to meet R1's needs and the psychosocial risk to other residents if R1 returned.
Complaint Details
The complaint investigation focused on the facility's refusal to readmit resident R1 after hospitalization despite a signed bed hold and the resident's activated power of attorney's request. The facility issued an improper 30-day discharge notice dated after the resident was already discharged and failed to provide the right to appeal. The resident's behaviors were cited as reasons for refusal, but the resident's condition had improved following psychiatric treatment. The facility closed the 2nd floor, limiting appropriate placement options, and refused to provide 1:1 supervision unless paid privately. The resident remains hospitalized due to lack of placement. The complaint was substantiated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to permit a resident to return to the facility following hospitalization and improperly discharged the resident without valid discharge planning or proper notice. | Level of Harm - Minimal harm or potential for actual harm |
| Facility lacks a policy and procedure regarding permitting residents to return to the facility after hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Bed hold coverage days: 15
Brief Interview for Mental Status (BIMS) score: 0
Date of hospitalization: Jan 28, 2023
Date of survey completion: Feb 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Named in multiple findings related to refusal to readmit resident R1 and discussions about discharge and bed hold. |
| DON B | Director of Nursing | Named in discussions about resident R1's discharge and refusal to readmit. |
| SW H | Social Worker | Involved in communications with family member and placement efforts for resident R1. |
| FM G | Family Member / Activated Power of Attorney for Health Care | Named as the resident's health care decision maker advocating for resident's return to the facility. |
Inspection Report
Annual Inspection
Deficiencies: 10
Jan 25, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident care, safety, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including inadequate supervision of residents leading to abuse, failure to timely report and investigate abuse allegations, improper medication administration and late medication delivery, inadequate infection control practices, unsafe storage of medications and chemicals, insufficient activities programming, failure to provide appropriate pressure ulcer care, and lack of proper documentation for immunizations and staff illness tracking.
Severity Breakdown
Immediate jeopardy: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision of resident R291 who exhibited socially inappropriate and aggressive behaviors, resulting in physical and verbal abuse of other residents. | Immediate jeopardy |
| Failure to timely report and thoroughly investigate allegations of abuse involving residents R290 and R291. | — |
| Failure to provide appropriate assistance with activities of daily living for resident R24, resulting in poor nutrition and skipped meals. | — |
| Failure to provide an ongoing, individualized activity program for residents R4, R34, R291, and R2, including lack of social history assessments and failure to incorporate resident preferences. | — |
| Failure to provide consistent pressure ulcer care and prevent further development of pressure injuries for resident R28, including missed treatments and lack of reapproach after refusals. | — |
| Failure to provide adequate supervision and assistive devices to prevent accidents and wandering for resident R291, and failure to maintain a safe environment free of hazards including unsecured chemicals and medications left at bedside. | Immediate jeopardy |
| Failure to ensure medication administration staff have appropriate competencies and training, including observed improper nasal spray administration and lack of orientation for agency staff. | — |
| Failure to ensure drugs and biologicals are properly labeled and stored, including expired medications and unlabeled insulin pens. | — |
| Failure to provide documentation of influenza and pneumococcal vaccinations or declinations for residents R4 and R7, and failure to update vaccination policies to include current CDC recommendations. | — |
| Failure to maintain an effective infection prevention and control program, including incomplete employee illness tracking, contaminated water fountains, unclean wheelchairs, improper hand hygiene by staff, and unsafe ice handling practices. | — |
Report Facts
Sample size: 18
Sample size: 10
Days activity offered: 48
Activity participation: 28
Days behavior documented: 20
Medication administration delays: 15
Expired medications: 2
Expired medications: 3
Fruit flies observed: 5
Hand sanitizer bottles: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MT T | Medication Technician | Observed administering nasal spray incorrectly and poor hand hygiene |
| LPN G | Licensed Practical Nurse | Administered insulin without hand hygiene or gloves, unsure of nasal spray administration procedure |
| RN J | Registered Nurse | Reported difficult shift with agency staff, assisted with grievance for abuse incident |
| ADON C | Assistant Director of Nursing | Interviewed regarding abuse incident reporting and agency staff orientation |
| DON B | Director of Nursing | Provided documentation on 15-minute checks, hand hygiene expectations, and medication administration |
| IP C | Infection Preventionist | Interviewed regarding infection control program, employee illness tracking, and water fountain maintenance |
| Maintenance E | Maintenance Supervisor | Interviewed regarding pest control and water fountain maintenance |
| CNA U | Certified Nursing Assistant | Reported on wandering resident supervision and behavior |
| AA KK | Activity Aide | Reported on resident behaviors and activity plans |
| CNA I | Certified Nursing Assistant | Reported on wandering resident behaviors and supervision |
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