Abbotsford Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Abbotsford, Wisconsin.
- Location
- 600 E Elm St, Abbotsford, Wisconsin 54405
- CMS Provider Number
- 525435
- Inspections on file
- 27
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Abbotsford Health Care Center during CMS and state inspections, most recent first.
A resident with intact cognition reported missing money after a hospital stay, stating $200 was gone while staff had only verified seeing $50 in the room. The facility’s investigation included interviewing the resident, searching for the money, contacting law enforcement, and interviewing staff, but it could not confirm the total amount missing beyond the $50 observed. Although the facility’s abuse/exploitation policy required interviewing all involved persons and providing staff training with demonstrated competency, there was insufficient evidence that residents were systematically interviewed about missing items or that staff received timely misappropriation education, and other residents did not recall being questioned about missing belongings.
A resident was accepted for admission from a hospital with the understanding that she was a pivot transfer, but upon arrival she was placed in a too-small wheelchair, slid to the floor when reaching down, and was sent to the ED by EMS because staff could not get her up. The facility’s record contained only pre-admission documents and lacked admission notes, assessments, incident documentation, or discharge records. Leadership acknowledged that no admission paperwork was completed and that the facility lacked appropriate bariatric equipment, yet there was no documented assessment of transfer status, no evidence that the resident or representative received required written transfer/discharge notices, appeal rights, Ombudsman contact information, or bed-hold and return-rights information, and no documented communication with the hospital explaining the reason for discharge or confirming re-admission.
A resident with severe cognitive impairment, history of falls, and documented wandering and elopement risk was care planned to have a Wanderguard and redirection from doors, but surveyors observed the resident without a Wanderguard or chair alarm and independently leaving the room and entering another resident’s room before staff intervened. Staff confirmed the resident was supposed to always wear a Wanderguard, yet could not account for how long it had been off, including around the time of a recent fall and ED visit, and there was no documentation of assessments or routine checks to ensure the device was in place, despite facility policies requiring elopement assessment, care planning, and implementation of accident-prevention interventions.
Two residents did not receive proper skin assessments and wound documentation as required by professional standards. One resident with a surgical incision did not have assessments or documentation of the wound site, including after the removal of steri strips and an episode of bleeding. Another resident with multiple comorbidities and a new heel wound did not receive a comprehensive initial wound assessment, with missing documentation of wound size and delayed follow-up.
A resident admitted with an unstageable pressure injury to the left heel did not receive a comprehensive PI assessment, including measurements and description, upon admission. The initial assessment only noted the presence of the PI, and a detailed wound assessment was not completed until several days later by the wound clinic. The DON confirmed that a complete assessment was expected but not documented.
A resident with moderate cognitive impairment and a history of wandering left the facility without staff authorization after independently arranging transportation. Although the care plan noted the guardian's permission for the resident to leave for smoking, no new interventions or monitoring were added following the incident, despite facility policy requiring updates to care provision after such events.
A resident with mild cognitive impairment and a history of wandering left the facility without staff knowledge or authorization after independently arranging transport, despite care plan requirements for supervision. The facility lacked documentation of sign-out procedures, did not complete a thorough investigation, and failed to educate staff on elopement protocols following the incident.
The facility did not complete required background checks for an employee before hire, as mandated by its abuse prevention policy. Due to miscommunication between the facility and corporate office, the employee began working without a Background Information Disclosure, DOJ response, or Government Findings report, and was observed in resident care areas despite the lack of screening.
A resident with multiple diagnoses and intact cognition had side rails removed from her bed after a hospital stay, but the care plan was not updated to reflect this change. Despite audits indicating updates, the care plan continued to list side rails as an intervention, and the resident did not receive an alternative assistive device as discussed. The DON confirmed the removal was per protocol and that side rails would not improve mobility, but the care plan was not revised accordingly.
The facility did not have a director of food and nutrition services who met the minimum qualification requirements, as the current Dietary Manager is still completing the necessary certification program. Additionally, there is no full-time Registered Dietician on staff, with the RD only present one to two days per week. This deficiency could potentially impact all residents in the facility.
Surveyors observed improper food handling and storage practices, including stacking wet dishes, unsanitary handwashing sinks, and unlabeled or undated food items in refrigerators and freezers. Staff acknowledged these actions did not meet facility policies or food safety standards.
Surveyors found widespread frayed carpeting, stained floors, and damaged walls throughout the facility, with staff unable to identify the causes of carpet spots or provide documentation of follow-up. The Maintenance Director reported limited cleaning and maintenance, and the DON confirmed the issues had persisted for an extended period. These deficiencies affected all areas used by residents, staff, and visitors.
Two residents did not have complete, person-centered care plans: one lacked documented accommodations for vision and hearing deficits during activities and had no assessment or interventions for meal preferences, while another did not have a safe smoking plan in place despite being observed smoking unsupervised and having physical limitations. Staff interviews and record reviews confirmed these omissions.
A resident with diabetes and chronic wounds did not receive consistent wound care, as treatment orders from the wound clinic were not promptly transcribed or implemented, nutritional and zinc supplement recommendations were missed, and a protective boot was not applied as ordered. Documentation and monitoring of wound care were incomplete, and staff interviews revealed confusion about order follow-through, resulting in gaps in necessary treatment and services to promote wound healing.
Surveyors observed two residents for whom infection control protocols were not followed: a resident's catheter bag was repeatedly seen dragging on the floor while attached to a wheelchair, and during a dressing change for another resident, clean gauze and a measuring tool were contaminated by contact with the floor and then used in the procedure. Both the infection preventionist and DON confirmed these practices did not meet facility expectations.
A facility failed to ensure the safety of mechanical lifts and proper sling size determination, leading to an incident where a resident was injured during a transfer. Staff were unaware of how to select the correct sling size, and maintenance staff lacked training to inspect lift safety. The facility did not have a system for labeling sling sizes or a reference chart, contributing to potential risks for all residents using mechanical lifts.
A resident with dementia and a fall risk was injured during a Hoyer lift transfer when a CNA failed to follow the facility's policy requiring two staff members for such transfers. The CNA attempted the transfer alone, resulting in the resident slipping from the sling and sustaining severe head injuries. The incident highlighted a lack of adherence to established procedures and inadequate supervision during the transfer.
The Bedrock corporation governing body failed to maintain current payments with service providers, leading to service disruptions and potential risks to resident care. The facility's aging vendor report showed significant outstanding balances, some over three years old. The Nursing Home Administrator was unaware of past due amounts and payment statuses, indicating a lack of communication and oversight.
A resident with severe cognitive impairment and multiple medical conditions was sent to the hospital for emergency evaluation but faced a delay in returning to the facility due to confusion over transportation responsibilities. The facility and managed care organization were unclear about who should arrange transport, resulting in the resident staying overnight at the hospital. The facility's van service operates only during daytime hours, and alternative options were unavailable, highlighting a recurring issue in rural areas.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and unmet resident needs. Observations and interviews revealed that residents waited extended periods for assistance, with staff overwhelmed by high acuity demands. Despite complaints, the administration did not effectively address staffing concerns, leading to ongoing deficiencies in care.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of a resident’s money and did not ensure required interviews were completed. One cognitively intact resident (BIMS 15/15) reported that $200 was missing after returning from the hospital, while staff had previously observed a $50 bill in the resident’s room the day before. The facility’s investigation included an interview with the resident, a search for the missing money that was not found, contact with law enforcement, and staff interviews. However, the amount of money allegedly missing could not be confirmed beyond the $50 observed by staff, and the resident continued to state that $200 was missing. The facility’s abuse/neglect/exploitation policy required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, as well as training staff on changes made and demonstrating staff competency after training. During the survey, the Social Services Director stated that resident interviews were conducted through daily “Angel Rounds” and provided a blank Angel Rounds form and a typed list of 26 residents with yes/no responses regarding missing items, with only the involved resident reporting missing money. Other interviewed residents did not recall being interviewed about missing items or money. A CNA familiar with the incident reported not remembering any staff education or training related to misappropriation after the money was reported missing. The surveyor determined the facility did not complete a thorough investigation due to lack of evidence of resident interviews and lack of timely staff training on misappropriation.
Failure to Document Admission/Discharge and Provide Required Transfer, Appeal, and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with required transfer/discharge notices, appeal rights information, Ombudsman contact information, and written bed-hold and return-rights information, as well as failure to document the admission, fall, and discharge. A resident (R7) was accepted for admission from a referring hospital with the understanding that she was a pivot transfer. Upon arrival, she traveled approximately two hours and was placed in a wheelchair that was too small. Shortly after arrival, while seated in the wheelchair, she reached down to pick something up and slid from the chair onto the floor. EMS was called because staff were unable to get her up from the floor, and she was transported to the emergency room. The facility’s electronic record for the resident contained only pre-admission documents such as advance directives, hospital discharge summary, and insurance information, but no admission documentation, progress notes, assessments, incident reports, or discharge documentation. The facility’s Admissions Coordinator stated that the resident was not admitted to the facility and reported that the resident could not transfer as reported by the hospital, slid from the wheelchair, and was sent to the hospital via EMS. The Nursing Home Administrator, however, stated that the facility had accepted the resident as an admission and that no admission paperwork had been completed. The Administrator reported that therapy was asked to assess the resident’s transfer status, but before that occurred, the resident had already fallen from the wheelchair. The Administrator stated that the facility did not have the appropriate equipment, such as a bariatric hoyer lift or sling, to care for the resident when it was determined she could not pivot transfer. The facility did not provide evidence that the resident was assessed at the facility to determine her transfer status, nor did it provide documentation that the resident’s needs could not be met in the facility as required by its transfer/discharge policy. The facility did not provide evidence that the required transfer/discharge process was followed. There was no documentation that the resident or her representative received written notice of transfer or discharge, including the specific reason for transfer, effective date, location of transfer, appeal rights, or the name, address, phone number, and email of the State Long-Term Care Ombudsman. There was also no evidence that the resident or representative received written information on the facility’s bed-hold duration, reserve bed payment policy, or the right to return to the facility. The facility did not provide evidence of communication with the receiving hospital explaining the reason for the resident’s discharge or documenting agreement to re-admit the resident. Although the Administrator reported being told that a correct hoyer sling would be ordered for the resident, the facility did not provide evidence that such a sling was ordered. The facility was unable to provide evidence that its own transfer and discharge policy requirements were met for this resident. The surveyor’s review of communications showed only an email chain in which the Admissions Coordinator initially accepted the resident for admission and later informed the referring hospital that there were issues when the resident arrived, that she could not transfer as reported, and that she slid to the floor and was taken to the hospital by ambulance. No further communication with the hospital after the resident’s transfer was provided. A discharge summary from the receiving hospital documented follow-up needs related to deconditioning, weakness, ankle and knee instability, bariatric management, and UTI, but the facility did not produce any pre-admission assessment indicating the resident’s transfer status or any documentation that the discharge process, including notices and appeal information, was followed. Overall, the facility failed to document the resident’s admission, fall, and discharge and failed to provide the required notices and information related to transfer/discharge, appeal rights, Ombudsman contacts, and bed-hold and return policies.
Failure to Maintain Wanderguard and Supervision for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of assistance devices to prevent accidents for one resident identified as an elopement risk. The resident had diagnoses including altered mental status, history of falling, alcohol dependence with withdrawal delirium, age-related physical debility, and metabolic encephalopathy, and an MDS BIMS score of 00 indicating severe cognitive impairment. The baseline care plan identified the resident as at risk for elopement related to wandering and specified interventions including a Wanderguard on the right wrist and redirection from doors. Facility policies on elopement and accidents/supervision required elopement risk assessment at admission, development of an elopement prevention care plan, use of an alarm system to notify staff when exit doors are opened, and implementation of specific interventions to reduce risk from environmental hazards, including adequate supervision. On the survey date, the NHA identified the resident as one of two residents using the Wanderguard system, but the surveyor observed the resident alone in a wheelchair without any Wanderguard device in place and speaking incoherently about needing to meet family. A CNA confirmed the resident was supposed to always have a Wanderguard but could not locate it, and an RN then placed a Wanderguard on the resident’s ankle, stating the resident had fallen the previous night and been sent to the ED, with no ability to determine how long the resident had been without the device. The surveyor later observed the resident independently exit the room at a fast walk, cross the hall, and enter another resident’s room without a chair alarm in place, requiring immediate staff intervention and redirection. Record review showed prior documentation of wandering and attempts to go through doors looking for beer, with a Wanderguard previously placed due to elopement risk, but there was no documentation regarding whether the Wanderguard was in place before or after the fall and ED visit, no documentation of assessment upon return, and no CNA or nursing documentation of routine monitoring to ensure the Wanderguard was in place. Staff interviews indicated reliance on a binder listing residents requiring Wanderguards and a shared responsibility among all staff interacting with the resident to ensure the device was in place.
Failure to Complete and Document Wound Assessments
Penalty
Summary
The facility failed to provide appropriate skin assessments and treatment in accordance with professional standards of practice for two residents. For one resident with multiple traumatic injuries and a surgical incision on the left upper extremity, staff did not assess or document the condition of the surgical site, nor did they document the removal of steri strips as ordered. There was no evidence of ongoing assessments of the surgical incision, despite a physician's order for dressing changes and a noted incident of partial dehiscence and bleeding at the site. For another resident with a history of chronic ulcer, diabetes, peripheral vascular disease, and recent amputation, staff did not complete a comprehensive wound assessment when a new wound was first identified. The initial documentation lacked details such as wound size, and there was a delay in completing a full assessment. The resident was later found to have a pressure ulcer on the left heel, but the facility did not have documentation of an initial assessment with measurements when the wound was first discovered.
Failure to Complete Comprehensive Pressure Injury Assessment on Admission
Penalty
Summary
A deficiency occurred when staff failed to implement professional standards of practice for pressure injury (PI) care and prevention for a resident admitted with an unstageable PI to the left heel. Upon admission, the resident had multiple diagnoses including hemiplegia, hemiparesis, MRSA infection, deep tissue damage to the left heel, diabetes mellitus, protein-calorie malnutrition, atrial fibrillation, chronic kidney disease, anxiety disorder, and depression. The resident was assessed as having intact cognition but required moderate to maximum assistance with activities of daily living and was identified as being at risk for pressure injuries. Despite the presence of a pressure injury on admission, staff did not complete a comprehensive PI assessment that included measurements and a detailed description of the wound. The initial clinical assessment only noted the existence of an unstageable PI without further specifics. The first documented wound assessment with measurements and description was not completed until several days after admission by the wound clinic. During an interview, the DON confirmed that there was no documented comprehensive admission assessment of the PI, despite acknowledging that such an assessment was expected.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Documentation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a resident leaving the premises without staff knowledge or authorization. The resident, who was under guardianship and had diagnoses including mild cognitive impairment and a history of wandering and elopement, was permitted by their guardian to leave the facility to smoke, as the facility is smoke-free. Despite this, the resident's care plan required staff supervision due to confusion and altered mental status. On the day of the incident, the resident independently arranged for transport and left the facility to attend an appointment that had been previously canceled by the guardian, without signing out or informing staff. The facility's investigation into the incident was incomplete, as there was no documentation of resident or staff interviews, and no evidence that the resident had been signing out when leaving the premises. Staff members, including CNAs, reported not receiving education on elopement procedures following the incident, and the DON was unable to provide documentation of interventions implemented to prevent recurrence. The facility's policy required adequate supervision for residents at risk of elopement, but this was not followed in the case of this resident.
Failure to Screen Employee for Abuse and Neglect History Prior to Hire
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one of eight employees reviewed, identified as Intern D, was hired without the required Background Information Disclosure (BID), Department of Justice (DOJ) response, or Government Findings report being completed prior to starting work. The facility's policy mandates that all potential employees, including students affiliated with academic institutions, must undergo background, reference, and credential checks before employment. During the survey, it was discovered that both the facility and the corporate office assumed the other party was responsible for conducting Intern D's background check, resulting in the process not being completed. Despite this oversight, Intern D was observed in resident care areas obtaining paperwork for surveyors, even though the administrator stated that Intern D was being kept in the office. This failure to follow established screening procedures directly contravened the facility's abuse prevention policy.
Failure to Revise Care Plan After Removal of Side Rails
Penalty
Summary
The facility failed to revise the care plan for a resident after the removal of side rails from her bed. The resident, who had diagnoses including congestive heart failure, morbid obesity, and anxiety disorder, was cognitively intact and had previously expressed a desire to have side rails to promote independence. The care plan, last updated in June, still listed side rails as an intervention for mobility impairment, despite their removal. Audits by the speech-language pathologist indicated the care plan had been updated, but the intervention remained unchanged in the documentation. Observations on July 8 confirmed that the resident's bed no longer had side rails, and the resident reported that the rails were removed during a hospitalization and not returned, with no alternative assistive device provided as promised. The DON confirmed the side rails were removed per protocol after the resident's hospital discharge and stated that side rails would not improve the resident's bed mobility. The failure to update the care plan to reflect the removal of side rails constituted the deficiency.
Lack of Qualified Director and Full-Time Dietician in Food and Nutrition Services
Penalty
Summary
The facility failed to designate a director of food and nutrition services who met the minimum qualification requirements as outlined in their own policy. The current Dietary Manager (DM) is enrolled in a Nutrition & Food Service Professional Program but has not yet completed it, having received an extension to finish the program by a later date. The facility policy requires the director to have certification as a dietary manager, certification as a food service manager, an associate or higher degree in food service management or hospitality with relevant coursework, or at least two years of experience in the position along with completion or enrollment in a food safety management course. The DM does not currently meet these qualifications, as she is still in the process of completing her required program. Additionally, the facility does not have a full-time Registered Dietician (RD) on staff. The RD is only present in the facility one to two days per week, which does not fulfill the requirement for a full-time RD. This lack of appropriately qualified staff in the food and nutrition services department could potentially affect all 48 residents residing in the facility, as noted by the surveyor during interviews and record review.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to prepare, store, and distribute food in a sanitary manner, as evidenced by multiple observations and staff interviews. A dietary aide was seen removing clean drinking glasses and plastic mixing containers from the dishwasher, stacking them together while still wet, and placing them in storage, causing water to drip on the floor and counter. The dietary aide acknowledged that dishes should be dry before being stacked and stored, and the dietary manager confirmed that this practice did not meet facility expectations or established food safety standards. Additionally, the kitchen's handwashing sink was observed to have heavy lime and dirt buildup on the faucet handles, drain, and basin. The dietary aide was unable to recall when the sink was last deep cleaned, and the dietary manager confirmed that the cleanliness of the sink did not meet expectations. The cleaning schedule was found to be lacking a specific task for deep cleaning the handwashing sink, which was only added after the surveyor's observation. Further deficiencies were noted in the storage of resident food brought in from outside sources. Refrigerators and freezers contained multiple opened food items without labels indicating the contents, resident names, or dates. Some food items prepared by the facility and not consumed during mealtimes were also stored without proper labeling. The dietary manager acknowledged that these practices did not meet facility policy and expressed concern about the potential for expired foods to cause foodborne illness.
Environmental Deficiencies: Unsafe, Unsanitary, and Uncomfortable Facility Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for all 48 residents, as evidenced by multiple observations of frayed carpeting, stained flooring, and damaged walls throughout the building. Surveyors noted frayed carpet in several hallways and common areas, with specific mention of fraying around metal circles in the floor and along seams. Numerous dark and white spots were observed on the carpets in various hallways, with some spots being large in size. Staff, including housekeeping, RN, and DON, were unable to identify the cause of the spots, and the DON confirmed that the spots had been present since her hire date in 2022. The Maintenance Director indicated that the carpets had been shampooed only a few times in the past six months and suggested that improper cleaning or treatment may have contributed to the stains. Additionally, a bathroom floor was found to be completely stained, and staff acknowledged the poor condition of the flooring. Further deficiencies were observed in the condition of the walls, including unfinished sheetrock, puncture marks, black marks, missing paint, and cracks. The Maintenance Director attributed some of the wall damage to wheelchairs or carts and acknowledged being unable to address all maintenance needs due to limited staffing. The DON stated that these issues had been reported to corporate but was unable to provide documentation of any follow-up. No specific residents were identified as being directly affected at the time of the survey, but the environmental deficiencies were present in areas accessible to all residents, staff, and the public.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed all identified needs and preferences for two residents. For one resident, there was no activity care plan that included accommodations for vision and hearing deficits, despite the resident reporting difficulty hearing and seeing during activities such as bingo, and needing to sit close to the caller to participate effectively. The resident also stated that food preferences were not assessed or accommodated, and no alternatives were offered for foods she could not eat. Review of the care plan and interviews with staff revealed that vision and hearing accommodations, as well as specific food preferences, were not documented or implemented, and the process for assessing and updating these preferences was inconsistent or incomplete. For another resident with a history of spina bifida, pressure ulcers, osteomyelitis, and catheter-associated urinary tract infections, the care plan did not include a safe smoking plan, even though the resident was observed smoking outside without staff assistance and was unable to pick up a dropped lighter. Although a smoking safety assessment indicated the resident could smoke without supervision, the care plan lacked details on supervision requirements, safety measures, and storage of smoking materials. Staff interviews confirmed that the omission of a smoking care plan was an oversight.
Failure to Provide Ordered Wound Care and Services for Resident with Diabetic Ulcers
Penalty
Summary
A resident with multiple chronic conditions, including diabetes, peripheral vascular disease, and a history of wounds, did not receive necessary wound care and related services as ordered. The resident had active wound treatment orders that lapsed for several days, leaving a period with no documented wound care provided. Orders from a wound clinic, including those for nutritional supplements and the use of a protective boot, were not transcribed or implemented in a timely manner. Additionally, recommendations from a registered dietician for a zinc supplement to promote wound healing were not addressed or documented as ordered. Observations and interviews revealed that wound care was not consistently performed according to the prescribed schedule, and the resident reported that dressing changes were missed for up to two days. The Prevalon boot, ordered to be worn at all times, was not consistently applied, with documentation showing it was only in use during certain shifts and not daily as required. There was no evidence of resident refusal or documentation of risks and benefits related to the boot in the care plan. The treatment administration record (TAR) did not reflect all required treatments, and staff interviews indicated confusion or lack of clarity regarding the implementation and monitoring of wound care orders. The facility's failure to ensure timely transcription and implementation of physician and wound clinic orders, as well as to follow through on dietician recommendations, resulted in gaps in care for the resident. Documentation and monitoring were inconsistent, and there was a lack of communication and follow-up regarding new orders and recommendations. These actions and inactions led to the resident not receiving the necessary treatment and services to promote wound healing as required by facility policy and physician directives.
Failure to Maintain Infection Control During Catheter Care and Dressing Change
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two of four sampled residents. For one resident with a urinary catheter, repeated observations showed the catheter urine collection bag was positioned on the lowest part of the wheelchair crossbars, causing it to rest on and drag across the floor as the resident moved throughout the facility. The facility's catheter care policy did not address proper positioning of the catheter bag, and the infection preventionist confirmed that catheter bags should be kept off the floor to prevent contamination. In a separate incident, during a dressing change for another resident with multiple pressure injuries and receiving hospice care, clean gauze intended for use between the toes was observed touching the floor and lying under the nurse's foot. Additionally, the measuring tool used for wound assessment was also in contact with the floor. The nurse acknowledged that items which had touched the floor should not have been used during the dressing change, and the Director of Nursing confirmed this expectation.
Deficiency in Mechanical Lift Safety and Sling Size Determination
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically concerning the use of mechanical lifts for resident transfers. On one occasion, staff did not verify the proper sling size or the safe functioning of the mechanical lift before transferring a resident, resulting in the lift tipping over and causing the sling bar to strike the resident in the face. This incident led to a bruise and laceration below the resident's left eye, requiring hospital transfer and tissue adhesive repair. Observations revealed that staff were not aware of how to determine the proper sling size for residents, and the care plans did not specify the type or size of sling to be used. The maintenance staff lacked the necessary knowledge to inspect and ensure the safety of the mechanical lifts. The Maintenance Director admitted to not receiving specific training on the equipment and was unable to determine if the lifts were operating safely. A mechanical lift used in the incident had a defect that allowed its base legs to move to a closed position without using the foot lever, a condition that had been reported but not addressed. This lack of proper maintenance and inspection posed a safety risk to all residents using mechanical lifts. Additionally, the facility did not have a clear system for determining and labeling sling sizes. Staff relied on visual comparison to choose slings, as there were no labels or reference charts available to guide them in selecting the appropriate size based on residents' weight and height. The Nursing Home Administrator was unaware of the manufacturer's guidelines for sling size determination and the available sizes in the facility. This lack of knowledge and resources contributed to the potential for unsafe transfers, affecting all residents who required mechanical lifts.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during a Hoyer lift transfer for a resident, leading to a serious accident. A Certified Nursing Assistant (CNA) transferred the resident using a Hoyer lift without the required assistance of another staff member, contrary to the facility's policy that mandates two people for all mechanical lift transfers. During the transfer, the resident slipped out of the sling and fell to the floor, resulting in a subarachnoid hemorrhage, subdural hematoma, and other injuries, necessitating hospitalization. The resident involved had a history of dementia and anxiety disorder and required total assistance with activities of daily living. The resident was identified as a fall risk, with a care plan that included the use of a Hoyer lift for transfers. On the day of the incident, the CNA did not request assistance from a nearby nurse and proceeded with the transfer alone, using an uncrossed sling, which was not specified in the care plan. This oversight led to the resident sliding out of the sling and sustaining severe head injuries. The incident was immediately investigated by the facility, revealing that the CNA was aware of the two-person policy but did not adhere to it. The facility had previously conducted education on Hoyer lift use, but the care plan lacked specific instructions on crossing the straps between the resident's legs. The failure to follow established procedures and ensure proper supervision during the transfer resulted in significant harm to the resident.
Removal Plan
- The facility completed resident care plan reviews for the residents who require mechanical lift transfers.
- The facility provided reeducation on mechanical lift use, requirement for 2 staff to be present during the entire transfer, and use walkie talkies to ask for assistance, and if unsure how to transfer a resident, staff is to seek clarification from a nurse.
- Licensed nursing staff educated on updating a resident care plan if the straps are to be crossed for the transfer.
- CNA C's employment with the facility was terminated.
Financial Mismanagement Leads to Service Disruptions
Penalty
Summary
The Bedrock corporation governing body failed to ensure adequate funds were available for the safe and efficient management of the facility, affecting all 51 residents. The governing body did not maintain current payment status with several service providers and vendors, leading to vendors refusing to provide services or issuing discontinuation notices until payment was received. This included the abrupt termination of the facility's pharmacy provider after a past due notice, and the potential disruption of services due to unpaid state bed taxes and civil money penalties. The facility's aging vendor report revealed significant outstanding balances with multiple vendors, some dating back over three years. The surveyor verified these balances with various service providers, confirming discrepancies between the amounts owed and those reported by the facility. For instance, the facility owed substantial amounts to a gas supplier, food supplier, and transportation services, with some services already halted due to non-payment. Additionally, the facility breached its contract with a garbage removal service, leading to legal action. The Nursing Home Administrator (NHA) was interviewed and stated that they only see invoices for services and supplies, which are then sent to corporate for payment. The NHA was not informed of past due amounts or when invoices were paid, and was unaware of the reasons behind the change in pharmacy service. Despite these financial issues, the NHA reported no disruptions in utilities, internet, or food services, although the facility's financial mismanagement posed a risk to the quality of care and life for residents.
Failure to Provide Timely Transportation for Resident
Penalty
Summary
The facility failed to provide necessary transportation services for a resident, identified as R2, who was sent to the hospital for an emergency evaluation due to chest pain and shortness of breath. R2, who has severe cognitive impairment and multiple medical conditions including atrial fibrillation and hepatocellular carcinoma, was discharged from the hospital on the same day but was unable to return to the facility until the following morning. This delay was due to confusion over transportation responsibilities between the facility and the managed care organization, resulting in R2 remaining at the hospital overnight. Interviews with facility staff and the managed care organization revealed a lack of clarity regarding who was responsible for arranging transportation for R2. The Assistant Director of Nursing and the Nursing Home Administrator both indicated that transportation is typically arranged by the managed care organization for residents under their care, but the facility also has a van service available during daytime hours. However, this service does not operate after hours, and alternative transportation options were not available. The facility's inability to secure transportation during off hours has been a recurring issue, particularly in rural areas where services are limited.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The staffing ratios did not align with the facility's assessment of staffing needs, particularly during the night shift, where the licensed nurse-to-resident ratio was higher than planned. This discrepancy resulted in delayed responses to call lights and unmet resident needs, as observed by surveyors and reported by residents and staff. Residents expressed dissatisfaction with the timeliness of care, with some waiting extended periods for assistance, leading to discomfort and unmet personal care needs. Multiple residents reported waiting for assistance with daily activities, such as getting ready for the day or being helped to the toilet, for extended periods. One resident, for example, had their call light on for nearly 45 minutes before receiving help. Staff interviews revealed that they were overwhelmed and unable to complete their tasks due to the high acuity of residents and insufficient staffing levels. The facility's staffing plan did not account for the increased needs of residents requiring two-person assistance or those with high acuity conditions, leading to rushed and incomplete care. The facility's failure to address staffing concerns was further highlighted by resident council minutes and grievance reports, which consistently noted issues with call light response times and inadequate staffing. Despite staff and resident complaints, the administration had not effectively addressed these concerns, resulting in ongoing deficiencies in care. The lack of agency staff and the facility's rural location compounded the staffing challenges, leaving the facility unable to meet the care needs of its residents adequately.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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