Alden Estates Of Countryside, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson, Wisconsin.
- Location
- 1130 Collins Road, Jefferson, Wisconsin 53549
- CMS Provider Number
- 525271
- Inspections on file
- 33
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Alden Estates Of Countryside, Inc during CMS and state inspections, most recent first.
An LPN failed to consistently perform hand hygiene before and after wearing gloves while conducting blood glucose checks for multiple residents, including those on enhanced precautions. The LPN was observed entering rooms, handling supplies, and cleaning equipment without following proper hand hygiene protocols, contrary to facility policy and infection prevention expectations.
A resident with a history of traumatic brain injury and chronic kidney disease was prescribed Keppra for 7 days as seizure prophylaxis, but due to the facility's failure to clarify and follow the physician's order, the medication was administered for an extended period. This led to the resident experiencing a significant decline, including lethargy, weight loss, and eventual hospital readmission for acute metabolic encephalopathy, with hospital records citing continued Keppra use as a contributing factor. The facility did not thoroughly investigate the medication error.
Surveyors found that the facility failed to comprehensively assess, care plan, and implement interventions for several residents at risk for or with pressure injuries. Multiple residents with complex medical conditions developed new or worsening wounds without timely or complete assessment, staging, or care plan updates. Staff sometimes performed wound care without proper documentation or licensure, and preventive measures such as pressure-relieving devices and positioning were inconsistently used. These failures resulted in the development of avoidable pressure injuries, including a stage 4 wound with osteomyelitis, and led to a finding of immediate jeopardy.
Staff did not consistently wear beard restraints while preparing and serving food, with observations of both the Dietary Director and a cook failing to properly cover facial hair as required by policy. This lapse in sanitary practice had the potential to affect all residents receiving meals.
The facility did not accurately submit required direct care staffing data to CMS, resulting in discrepancies in reported staffing levels and a low staffing rating. A newly licensed LPN was incorrectly reported as an aide, and a recent change in payroll vendors contributed to the reporting error. Despite maintaining minimum staffing levels according to schedules, the inaccurate classification of staff led to incomplete and incorrect PBJ data submission.
Surveyors observed multiple instances where residents were not treated with dignity, including a resident with an uncovered catheter drainage bag visible in public areas, a resident with dementia left unattended and without adaptive utensils during meals, and another resident dependent on staff for eating who was referred to as a "feeder" and left alone with food. Staff interviews confirmed these actions did not align with facility policies on dignity and respect.
Two residents were administered psychotropic medications without the required baseline AIMS assessments, as mandated by facility policy. One resident with Alzheimer's and dementia received an antipsychotic without any documented AIMS assessment, and another resident with multiple neurological and psychiatric diagnoses was given Memantine and Mirtazapine before an AIMS assessment was completed. This deficiency was identified through record review and staff interviews.
Two residents at high risk for falls did not receive adequate supervision or assistance devices as required by their care plans. One resident with Parkinson's and dementia experienced multiple unwitnessed falls, with facility investigations lacking key details such as call light response times and whether interventions were in place. Another resident with severe cognitive impairment and recent decline was transferred by a single staff member without a gait belt, despite a care plan requiring a mechanical lift with two staff, and the prompted toileting program was not consistently followed. Staff interviews revealed gaps in awareness and communication about residents' care needs.
A resident with a history of depression and other medical conditions expressed to a CNA that they did not want to live. Facility staff did not complete a suicidal evaluation, notify the physician or psychologist, or develop a care plan to address the resident's depression, despite policy requirements and subsequent assessments indicating moderate depressive symptoms. Interviews revealed staff were unclear on appropriate follow-up, and no interventions for mood concerns were documented.
A resident with multiple complex medical conditions did not receive required monthly drug regimen reviews by a licensed pharmacist for two months, as documented in the medical record. Facility leadership acknowledged the missing reviews and attributed one lapse to the resident's hospitalization, but no documentation was provided to account for the missed pharmacist reviews.
Two residents prescribed Eliquis for conditions such as atrial fibrillation and pulmonary embolism did not have documented monitoring for potential adverse effects like bleeding or bruising. Staff confirmed that monitoring should occur, but the facility lacked a policy for anticoagulant monitoring other than for Warfarin, and no evidence of monitoring was found in the medical records.
A resident with a physician order for a mechanical soft diet was served a regular diet meal instead of the required mechanically altered meal. The facility's policy outlines the need for food modification for those with chewing difficulties, but during meal service, only one of two residents with this diet order received the correct meal. The error was identified and reported, with no explanation provided for the dietary mistake.
A resident with severe cognitive impairment and recent right-hand weakness did not consistently receive adaptive eating utensils and cups as recommended by occupational therapy. Despite therapy's instructions and documentation by CNAs, the adaptive equipment was not always provided during meals due to unclear responsibilities and lack of care plan updates, resulting in the resident struggling to eat independently and safely.
Two residents with stage 3 pressure injuries and chronic wounds were not consistently placed on Enhanced Barrier Precautions (EBP) as required by facility policy and CDC guidance. Staff failed to follow EBP protocols during wound care, did not maintain proper documentation or signage, and demonstrated confusion about when to initiate or discontinue EBP. These lapses resulted in inadequate infection prevention and control for residents with ongoing wound care needs.
Three cognitively intact residents with significant medical histories were not offered or documented as having refused the pneumococcal vaccine upon admission, despite being eligible and lacking immunization records. The ADON reported not being aware of the requirement to address vaccinations at admission, and consents were only obtained after surveyor inquiry.
Surveyors found that three residents with complex medical conditions did not have documentation in their medical records indicating whether they were offered, received, or declined the COVID-19 vaccine. The ADON reported not being aware of the requirement to address vaccination status at admission, and consents were only obtained after the issue was raised by surveyors. No evidence was provided to show that these residents were offered or refused the vaccine at the time of admission.
A resident with severe dementia and escalating aggressive behaviors was not provided with increased supervision or individualized interventions, despite repeated incidents of agitation, wandering, and physical aggression toward staff and other residents. This lack of adequate monitoring allowed the resident to enter another resident's room and physically assault them after a fall, demonstrating the facility's failure to protect residents from abuse.
A resident with multiple comorbidities and on hospice care was transferred by a CNA without the required EZ-stand, resulting in knee pain and swelling. Despite ongoing complaints and visible injury, thorough assessments and vital sign monitoring were not completed, and communication with the physician, hospice, and responsible party was insufficient. The resident's condition declined, leading to death from a femur fracture, and the facility's failure to follow care plans and ensure timely assessment and notification led to an immediate jeopardy finding.
A resident with Parkinson's Disease and on hospice care was transferred by a CNA using a pivot transfer instead of the care-planned EZ stand, resulting in severe knee pain, swelling, and bruising. The incident was not immediately reported as a fall, and the resident's condition declined over several days, culminating in death. An autopsy confirmed a left distal femur fracture caused by the improper transfer, and the facility failed to provide adequate supervision and follow the resident's care plan.
The facility did not maintain adequate nursing staff as outlined in its Facility Assessment, resulting in residents experiencing long wait times for assistance, especially during busy periods and weekends. Two residents, one requiring a Hoyer lift and another dependent on oxygen, reported significant delays in care. Staff interviews confirmed frequent staffing shortages, particularly on weekends, and a review of schedules showed the facility was consistently below required nurse and CNA levels. Both residents and staff expressed concerns about the impact of these staffing shortfalls.
A resident with Parkinson's Disease, requiring an EZ stand and one-person assist for transfers, suffered a left distal femur fracture after being transferred incorrectly by staff. Despite the resident's complaints of severe pain and visible injury, the incident was not reported to the Nursing Home Administrator or State Agency as required by facility policy. The facility failed to document the event in its grievance log or submit a Facility Reported Incident, and leadership relied on an inappropriate reporting algorithm, resulting in a lack of timely investigation and reporting.
A resident who required an EZ stand for transfers was instead moved by a pivot transfer, resulting in pain, swelling, and bruising to the left knee, followed by a significant decline and death. Despite staff awareness of the incident and the resident's subsequent injuries, the event was not reported to the administrator or State Agency as required by facility policy. The medical examiner later determined the cause of death was a femur fracture consistent with a fall or drop, but the facility did not submit a Facility Reported Incident or notify authorities in the required timeframe.
Two residents were not seen by a physician or physician extender at the required intervals, with one resident lacking alternating visits between physician and nurse practitioner, and another experiencing extended gaps between physician assessments, contrary to facility policy and regulatory requirements.
Two residents experienced falls due to inadequate supervision and care planning. One resident, with multiple medical conditions, fell while receiving care, resulting in a laceration and femur fracture. The facility did not conduct a thorough investigation or implement specific interventions. Another resident, severely cognitively impaired, had multiple falls with one causing injury. The facility failed to complete thorough investigations or establish specific interventions to prevent further falls.
The facility failed to provide sufficient nursing staff to meet residents' needs, leading to long call light wait times and unmet care requirements. Residents and staff reported concerns about staffing shortages, particularly on weekends and nights. Staffing records showed consistent shortfalls in CNA numbers compared to assessed needs, with the facility failing to meet requirements on multiple days.
The facility failed to consistently provide water to residents, as required by their policy. Several residents reported only receiving water upon request, and some did not receive it at all. Observations confirmed the absence of water glasses in some rooms, and staff interviews revealed inconsistencies in water distribution practices. The Director of Nursing and other administrative staff were informed, but no explanation was provided for the inconsistency.
A resident with moderate cognitive impairment reported being yelled at and handled roughly by a CNA. The facility's Assistant Administrator was informed but did not document or formally investigate the allegations, only providing a verbal warning to the CNA. The lack of a formal investigation and documentation constitutes a deficiency in compliance with the facility's abuse policy.
A resident with multiple medical conditions was prescribed Lorazepam 0.5 mg every four hours PRN for anxiety without an end date. Upon review, the surveyor found the order lacked a stop date, which was later added by the Regional Nurse Consultant. The facility's policy did not address stop dates for PRN psychotropic medications, and staff were unclear about responsibility for ensuring these dates.
A resident with chronic pain did not receive their prescribed Oxycodone 5mg on multiple occasions due to issues with reordering and obtaining prescriptions. Despite the facility's policy to reorder medications in advance, the medication was unavailable on several dates, leading to significant pain for the resident. Staff interviews revealed challenges in obtaining timely prescriptions from the nurse practitioner, contributing to the deficiency.
A resident with a complex medical history, including dementia and a-fib, experienced significant changes in condition following unwitnessed falls. Despite symptoms indicative of a head injury, such as altered mentation, pain, and vomiting, the facility did not promptly consult the resident's physician, Medical Director, or Hospice provider. The facility's policy on Change in Condition, which outlines procedures for notifying physicians of any changes, was not followed. The lack of communication and coordination between facility staff, hospice provider, and the resident's physician led to a delay in appropriate medical intervention, contributing to the resident's deteriorating health status.
A nursing home faced deficiencies in preventing accidents and falls, particularly for a resident with dementia and anxiety, assessed as high risk for falls. The resident experienced two unwitnessed falls resulting in significant injuries, including head trauma and cognitive impairment. The facility did not conduct post-fall investigations or revise the care plan to address the risks. Incidents included a fall in the bathroom and another while reaching for an out-of-reach call light. There was inadequate documentation and notification to the medical team about the resident's changing condition, such as weakness and altered speech. Despite existing policies on fall prevention and post-fall protocols, these measures were not effectively implemented.
The report identifies deficiencies in the communication and coordination processes between hospice, the facility, the physician, and the power of attorney for a resident with complex medical conditions. The resident experienced significant changes in condition, including unwitnessed falls, altered mentation, slurred speech, and weakness. Critical information about these changes was not consistently relayed to the physician, power of attorney, or hospice, leading to lapses in comprehensive care planning and decision-making. Delays in notifying appropriate parties about significant changes impacted the continuity of care and the resident's evolving care needs.
A resident at high risk for pressure ulcers developed a stage 4 pressure ulcer on the back of the left lower leg due to the facility's failure to monitor the skin under a knee immobilizer. Despite hospital discharge instructions and physician orders, regular skin assessments were not conducted, and the ulcer was discovered during a random check by the Director of Nursing.
The facility failed to ensure proper N95 mask fit testing for staff exposed to COVID-19 and did not maintain a sanitary environment for a resident with a Foley catheter, leading to increased infection risk.
The facility failed to provide required written notice information related to resident transfers to the hospital, affecting seven residents. The notices lacked details on appeal rights and contact information for the Ombudsman and other relevant agencies. The facility acknowledged the issue but had not yet updated their forms and policies to comply with the requirements.
A resident with a history of multiple health issues experienced a left distal femur fracture, which was not reported to the State Survey Agency within the required 2-hour timeframe. The facility also failed to submit the investigation results within 5 working days. The Director of Nursing could not provide evidence that the injury was pathological and did not report the injury, believing it was unnecessary.
The facility failed to ensure individualized comprehensive care plans for two residents, one with an indwelling catheter and another on anticoagulant medication. Interviews with staff confirmed these oversights were due to missed updates and transitions in staff responsibilities.
A facility failed to ensure a resident with an indwelling catheter received necessary urology consult services. Despite hospital discharge instructions and nurse practitioner's notes indicating the need for follow-up, the facility did not arrange a urology consult after the initial referral was canceled due to a subsequent hospital stay. The resident was unaware of the reason for the catheter, and the facility did not adhere to its policy for catheter removal assessment.
A resident was not properly assessed for bed rail use, and the facility lacked evidence that risks and benefits were discussed with the resident or their representative. Despite an assessment indicating no need for side rails, the resident's bed had fixed grab bars. Staff interviews revealed inconsistencies in the communication and documentation of side rail assessments.
The facility failed to ensure sufficient nursing staff to meet the needs of residents, leading to consistent low weekend staffing and unmet staffing requirements. Residents voiced concerns about insufficient care, and staff confirmed ongoing low staffing issues. The facility's algorithm for determining CNA needs was not met, and the acuity of residents was not considered in staffing calculations.
The facility failed to ensure proper use and documentation of psychotropic medications for three residents. One resident did not receive a recommended gradual dose reduction for an antidepressant, another was prescribed PRN Lorazepam without a documented rationale for extending its use beyond 14 days, and a third was given Primidone for essential tremors but had an incorrect diagnosis of seizures listed in their records.
The facility failed to display required information, including contact details for pertinent State agencies and advocacy groups, in the main entrance, lobby area, and all six units. The missing postings included essential information for residents to file complaints and report violations.
Failure to Perform Hand Hygiene During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that staff consistently performed hand hygiene before and after wearing gloves during blood glucose checks for five residents. Observations revealed that an LPN performed hand hygiene at the medication cart but did not consistently perform hand hygiene before donning gloves or after removing them when conducting blood glucose monitoring. The LPN was seen entering resident rooms, including those under enhanced precautions, donning gloves and gowns without prior hand hygiene, and performing fingerstick glucose checks. In several instances, the LPN removed gloves and gowns outside the resident rooms and failed to perform hand hygiene before proceeding to the next task or resident. The LPN was also observed handling the glucometer, medication cart, computer, and other supplies without performing hand hygiene between glove changes or after glove removal. Supplies such as lancets and testing strips were retrieved and handled without appropriate hand hygiene, and the LPN was seen touching personal items, such as cart keys and pockets, in between resident care activities. In some cases, the LPN cleaned the glucometer while wearing gloves, removed the gloves, and then failed to perform hand hygiene before touching other surfaces or equipment. Interviews with the LPN confirmed the failure to perform hand hygiene as required. The facility's infection prevention policy specifies that hand hygiene must be performed before donning gloves and after removing them, especially when performing procedures involving potential exposure to blood or body fluids. The Infection Preventionist stated that it was her expectation for staff to follow these protocols, but the observed practices did not align with facility policy.
Failure to Clarify and Follow Physician Order for Keppra Results in Harm
Penalty
Summary
A significant medication error occurred when a resident with a history of traumatic brain injury, chronic kidney disease stage 3, heart failure, and dysphagia was prescribed Levetiracetam (Keppra) for 7 days as seizure prophylaxis following hospital discharge. The facility failed to clarify, accurately transcribe, and follow the physician's order, resulting in the resident receiving Keppra for an extended period beyond the intended 7 days. The hospital discharge summary and related documentation repeatedly indicated that Keppra was to be administered for only 7 days, but the facility continued administration for approximately two weeks longer than prescribed. During this period, the resident exhibited a decline in condition, including increased lethargy, decreased appetite, weight loss, and reduced participation in therapy. Family members raised concerns about the resident's lethargy and possible side effects of Keppra, but the medication was only tapered and not discontinued until much later. The resident's condition continued to deteriorate, leading to a hospital readmission where acute metabolic encephalopathy, aspiration pneumonia, and acute kidney injury were diagnosed. Hospital records specifically noted that the continued use of Keppra was a contributing factor to the resident's encephalopathy, and the medication was discontinued during the hospital stay. The facility's process for entering and verifying new medication orders involved multiple staff members, but there was a failure to clarify the duration of the Keppra order despite clear indications in the hospital documentation. Interviews with facility staff revealed a lack of thorough review and understanding of the discharge instructions, and no documentation of a thorough investigation into the medication error was provided. The facility's own policy defined medication errors as preventable events that may cause harm, yet the error was not recognized or reported by staff until it resulted in actual harm to the resident.
Failure to Assess, Care Plan, and Prevent Pressure Injuries Leads to Immediate Jeopardy
Penalty
Summary
Surveyors identified that the facility failed to ensure comprehensive assessment, care planning, and implementation of interventions to prevent and treat pressure injuries for multiple residents. Several residents with significant comorbidities, such as diabetes, heart failure, immobility, and cognitive impairment, were at risk for pressure injuries or developed new wounds while in the facility. In multiple cases, when new wounds or pressure injuries were discovered, there was no evidence of timely or comprehensive assessment, staging, or documentation. For example, one resident developed a pressure injury to the left buttock and a blood blister to the right great toe, but the medical record lacked a comprehensive assessment, and the care plan was not updated to reflect these new wounds or interventions to promote healing. Additionally, treatments were sometimes performed by unlicensed staff, and documentation of wound care was inconsistent or incomplete. Another resident with a history of hemiplegia, diabetes, and impaired mobility developed multiple pressure injuries, including a deep tissue injury (DTI) to the left medial foot and additional DTIs to the left lateral foot and fifth toe. The care plan was not updated to address the resident's specific positioning challenges, such as outward rotation of the left leg, and interventions like heel offloading were not consistently implemented or documented. Observations revealed that pressure-relieving devices were not always in use, and staff were sometimes unaware of new wounds. Comprehensive assessments and care plan updates were delayed or missing, and the facility did not ensure that all wounds were properly identified, staged, and treated according to standards of practice. In another case, a resident with severe cognitive impairment and total dependence for mobility developed a large intact blister on the left heel, later identified as a DTI. There was a delay of several days before a comprehensive assessment was completed, and wound measurements did not include depth until much later. The care plan was not promptly revised to reflect the new pressure injury or to implement additional preventive measures. Across multiple cases, surveyors found that the facility did not consistently perform or document comprehensive skin assessments, update care plans, or ensure that interventions were in place and followed, resulting in the development and worsening of pressure injuries. These failures led to a finding of immediate jeopardy, particularly in the case of a resident who developed a facility-acquired, avoidable stage 4 pressure injury with osteomyelitis.
Failure to Ensure Proper Use of Beard Restraints During Food Preparation
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as required by both facility policy and regulatory standards. Surveyors observed multiple instances where staff did not wear beard restraints properly or at all while preparing food in the kitchen. Specifically, the Dietary Director was seen preparing food with a beard net that did not cover the mustache, and a cook was observed entering the kitchen and preparing food on two separate occasions without donning a beard net. These observations were made during food preparation times and involved staff with facial hair that was not properly restrained, contrary to the facility's stated policy. Interviews with staff confirmed that there was an expectation for facial hair coverings, but the practice was not consistently followed. The facility's policy on hair covering was reviewed, and there was some confusion regarding the requirements, as an updated policy was presented during the survey. The policy required mustache or beard restraints for facial hair exceeding half an inch in length, but federal regulations require that no facial hair be exposed. The deficiency had the potential to affect all 111 residents dining in the facility, as it created a risk of physical contamination of food during preparation and service.
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate electronic submission of direct care staffing information to CMS, as required by federal regulations. During the review of Payroll Based Journal (PBJ) data for the second quarter, surveyors found discrepancies in the reported staffing levels, particularly noting excessively low weekend staffing and a one-star staffing rating. Upon review of the facility's weekend schedules and minimum staffing requirements, no discrepancies were found between scheduled and required staff. However, it was discovered that a Licensed Practical Nurse who had recently graduated and obtained licensure was still being reported as an aide in the PBJ submission, which contributed to the inaccurate data. Additionally, the facility had recently changed payroll vendors, and the reporting error was not corrected as intended for the first quarter. Interviews with the scheduler and the Nursing Home Administrator (NHA) revealed confusion regarding the reporting process and the source of the staffing data errors. The NHA acknowledged a reporting error and indicated that all hours, including agency staff, were supposed to be sent to corporate for submission. The scheduler described how staffing was managed during call-ins and confirmed that minimum staffing levels were maintained according to the facility assessment. Despite these efforts, the inaccurate reporting of staff roles led to the submission of incorrect staffing data to CMS, affecting the facility's reported staffing levels and ratings.
Failure to Maintain Resident Dignity and Respect During Care and Meals
Penalty
Summary
Multiple deficiencies related to resident dignity and respect were identified during surveyor observations and interviews. One resident with an indwelling urinary catheter was repeatedly observed without a privacy cover on the catheter drainage bag, both in her room and in common areas, making the bag visible to others. Despite care plan interventions specifying the use of a privacy cover and staff acknowledging the requirement for such covers, the resident's catheter bag remained uncovered on several occasions. The resident herself confirmed that the drainage bag was not always covered when she moved throughout the facility. Additional deficiencies were observed in the dining area involving two other residents. One resident with severe cognitive impairment and a diagnosis of dementia was seen sleeping with her head in her lap at the dining table, with food scattered around her bowl and no staff present to assist. Later, a CNA was observed feeding this resident while standing over her, contrary to facility training that requires staff to sit at eye level with residents during feeding to maintain dignity. The resident was also noted to lack adaptive utensils recommended by occupational therapy. Another resident, who was completely dependent on staff for eating due to severe cognitive and physical impairments, was referred to as a "feeder" by staff calling across the dining room. This resident was also left alone at a table with food placed in front of her, despite being unable to feed herself. Staff interviews confirmed that this was not appropriate and did not align with facility policies or training on maintaining resident dignity and respect.
Failure to Complete Required AIMS Assessments Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that two residents were free from chemical restraints by not performing required Abnormal Involuntary Movement Scale (AIMS) assessments prior to administering psychotropic medications. According to the facility's policy, a baseline AIMS assessment should be completed before starting antipsychotic medications, with reassessments every six months. For one resident with Alzheimer's disease and dementia, the surveyor found no evidence of an AIMS assessment in the electronic medical record despite the resident receiving Quetiapine Fumarate, an antipsychotic medication. The facility was unable to provide the requested AIMS assessment for this resident during the survey. Another resident, who had multiple diagnoses including Alzheimer's disease, dementia, and Parkinson's disease, was prescribed Memantine and Mirtazapine, both psychotropic medications. The surveyor noted that while an AIMS assessment was eventually provided, it was not completed prior to the initiation of these medications. The lack of timely AIMS assessments for both residents was confirmed through record review and interviews with facility staff, indicating non-compliance with the facility's own policy regarding the monitoring of residents on psychotropic medications.
Failure to Prevent Accidents and Ensure Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls received adequate supervision and assistance devices to prevent accidents. One resident with Parkinson's Disease, Lewy body Dementia, and congestive heart failure experienced multiple unwitnessed falls. The facility did not thoroughly investigate each fall to determine the root cause or confirm that all care plan interventions were in place and effective at the time of the incidents. Documentation revealed that the resident often attempted self-transfers despite being care planned for staff assistance and the use of a Hoyer lift. Investigations into the falls lacked critical information, such as call light response times, whether the bed was in the lowest position, and if other interventions were implemented. In several instances, the resident activated the call light as instructed, but still experienced a fall before staff arrived, and the effectiveness of this intervention was not evaluated. Another resident with severe cognitive impairment, a history of falls, and recent physical decline was not consistently provided with the required level of assistance for transfers and toileting. The care plan specified the use of a mechanical lift (Hoyer) with two staff for all transfers and a prompted toileting program to reduce self-transfer attempts. However, staff interviews and observations revealed that the resident was transferred by a single staff member without a gait belt, and the prompted toileting program was not consistently followed. Staff were not always aware of the resident's current transfer and toileting requirements, and documentation indicated that the resident continued to self-transfer, increasing the risk of falls. The facility's failure to ensure that care plan interventions were implemented and effective, to thoroughly investigate falls, and to provide adequate supervision and assistance devices for residents at high risk for falls resulted in repeated incidents. Staff interviews indicated a lack of awareness and communication regarding residents' care plans and interventions, and investigations did not consistently review whether all safety measures were in place at the time of each fall.
Failure to Provide Necessary Behavioral Health Services Following Resident's Expression of Not Wanting to Live
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being, as required by the comprehensive assessment and care plan. The resident, who had a history of depression, adjustment disorder, and other significant medical conditions, expressed to a CNA that they did not want to live. Despite this statement, there was no documentation that a suicidal evaluation was completed, the physician or psychologist was notified, or a care plan was developed to address the resident's depression or mood concerns. The facility's policy required staff to assess and respond to expressions of suicidal ideation or passive death wishes, including offering psychosocial support and developing a care plan for passive statements. However, after the resident's statement, the RN instructed the CNA to notify social services but did not follow up with the resident or ensure an assessment was completed. There was also no evidence that the psychologist was informed of the resident's statement, and no care plan was initiated to address the resident's depression, even after subsequent assessments indicated moderate depressive symptoms and a care area assessment recommended care planning for mood. Interviews with facility staff revealed a lack of clarity and follow-through regarding the appropriate response to the resident's statement. The RN could not recall which CNA reported the statement and did not know what interventions should have been implemented. The Director of Social Services stated the resident was not suicidal and did not complete an assessment at the time. The care plan did not address the resident's depression or its manifestations, and interventions for mood concerns were not documented, despite multiple triggers and recommendations for care planning.
Failure to Ensure Consistent Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review, including a review of the medical chart, for one of five residents reviewed. According to the facility's policy, the consultant pharmacist is required to review each resident's medication regimen monthly and provide a report to the director of nursing, with nursing staff responsible for following up with the prescribing physician as needed. For the resident in question, who had multiple complex diagnoses including pulmonary embolism, paraplegia, Parkinson's disease, Alzheimer's disease, dementia, mood disturbance, and anxiety, the electronic medical record showed that monthly medication reviews were not documented for two specific months. The surveyor found that the resident's medical record lacked evidence of pharmacist reviews for January and April, despite documentation of reviews in other months. When questioned, facility leadership acknowledged the missing reviews and explained that the resident's hospitalization in April may have contributed to the oversight, as the resident did not trigger for pharmacist review upon return. No documentation was provided to account for the missing reviews, confirming that the required monthly pharmacist review was not consistently performed for this resident.
Failure to Monitor Anticoagulant Therapy for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not adequately monitoring the use of anticoagulant medications, specifically Eliquis. One resident with a history of atrial fibrillation and hypertension, who was rarely to never understood, was prescribed Eliquis 5 mg twice daily. Review of the resident's medical records, including physician orders, MAR, and TAR, revealed no documented monitoring for potential adverse effects of the anticoagulant, such as bleeding, bruising, or fatigue, during the assessment period. Another resident, cognitively intact and diagnosed with pulmonary embolism, paraplegia, Parkinson's disease, Alzheimer's disease, dementia, mood disturbance, and anxiety, was also prescribed Eliquis 5 mg twice daily. Similarly, there was no documentation in the MAR or TAR of monitoring for signs and symptoms of adverse effects from the medication. Staff interviews confirmed that monitoring for side effects should occur and be documented, but the facility lacked a policy for monitoring anticoagulants like Eliquis or Xarelto, having only a policy for Warfarin. No further information or documentation was provided by the facility regarding monitoring practices.
Resident Served Incorrect Diet Despite Mechanical Soft Order
Penalty
Summary
A deficiency occurred when a resident with a physician order for a mechanical soft diet was served a regular diet meal instead of the prescribed mechanically altered meal. The facility's policy specifies that a mechanical soft diet is intended for individuals who have difficulty chewing, requiring certain foods to be modified for easier consumption. During a lunch observation, an aide prepared and served a regular diet plate to the resident who required a mechanical soft diet, while another mechanical soft meal was set aside and not served to the intended resident. The surveyor confirmed through interview and record review that two residents on the unit were prescribed mechanical soft diets, but only one received the correct meal. The error was identified when the aide removed the incorrectly served regular diet plate from the resident's table. The incident was discussed with the dietary director and reported to the nursing home administrator and director of nursing. No explanation was provided for why the wrong diet was served to the resident.
Failure to Provide Adaptive Eating Equipment as Recommended by Therapy
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and recent right-hand weakness did not consistently receive adaptive eating equipment as recommended by occupational therapy. The resident had a history of dementia and physical limitations, including a right-hand wrist drop, which led occupational therapy to recommend and implement the use of built-up handled utensils and two-handled cups to support the resident's independence during meals. Despite these recommendations, observations by the surveyor revealed that the resident did not have access to the required adaptive utensils and cups during two out of three observed meals. At times, the resident was left without staff assistance, resulting in spilled food and difficulty eating. Interviews with facility staff indicated confusion and lack of clarity regarding responsibility for ensuring the adaptive equipment was provided and documented in the care plan. The occupational therapist reported informing both unit and kitchen staff of the resident's needs and providing education sheets to the restorative nurse, who was expected to update the care plan. However, the restorative nurse did not place the necessary orders, and the dietary supervisor had not received the order through the nutrition management system, so the care plan was not updated to reflect the adaptive equipment requirement. Staff interviews also revealed uncertainty about where information regarding adaptive equipment could be found, and some staff were unaware of the resident's current needs. Documentation showed that certified nursing assistants were recording the use of adaptive utensils in their daily charting, but this was not consistently reflected in the resident's care plan or meal setup. The lack of coordination among therapy, nursing, restorative, and dietary departments led to the resident not receiving the prescribed adaptive equipment during meals, as observed by the surveyor. This failure to provide necessary adaptive eating devices as recommended by therapy and outlined in facility policy resulted in the identified deficiency.
Failure to Implement Enhanced Barrier Precautions for Residents with Chronic Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with chronic wounds and stage 3 pressure injuries. For two of six residents observed, there were lapses in following facility policy and CDC guidance for EBP. One resident was readmitted with a hospital-acquired stage 3 pressure injury and was placed on EBP; however, there was no visible indication of EBP in place during surveyor observations, and the care plan documented discontinuation of EBP before the wound had fully healed. During wound care, the nurse did not follow EBP protocols, and staff interviews revealed uncertainty about the resident's EBP status and the criteria for discontinuing precautions. Another resident with a history of chronic wounds and a stage 3 pressure injury was not placed on EBP until after surveyor observation of drainage from leg wounds. The care plan lacked documentation of EBP implementation following the resident's hospital readmission with a stage 3 pressure injury. Staff interviews indicated confusion about when EBP should be initiated and who is responsible for making that decision. There was also a delay in placing the resident on EBP after the onset of wound drainage, and staff were unclear about the chronicity and management of the wounds. Throughout the investigation, surveyors noted inconsistent application of EBP, lack of proper signage, and inadequate communication among staff regarding infection control measures. Staff members, including the DON and ADON, provided conflicting information about the criteria for EBP and the status of residents requiring precautions. Observations included therapy and nursing staff providing care without appropriate personal protective equipment, despite care plans indicating EBP was still in effect. These actions and inactions resulted in the facility not maintaining a safe and sanitary environment to prevent the transmission of communicable diseases and infections.
Failure to Offer and Document Pneumococcal Vaccinations for Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered or refused as required for eligible residents. This deficiency was identified through interviews and record reviews, which revealed that three out of five residents whose immunization records were reviewed did not have documentation of being offered the pneumococcal vaccine upon admission. In each case, the lack of documentation persisted until after the surveyor requested evidence, at which point verbal consents were obtained. Specifically, one resident with a history of pulmonary embolism, lobar pneumonia, acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and chronic systolic heart failure was admitted without any record of being offered the pneumococcal vaccine. The Wisconsin Immunization Registry also did not show any record of administration, and the resident was eligible for the vaccine. Two other residents, both cognitively intact and with significant medical histories including enterocolitis, diabetes, COPD, heart failure, cellulitis, and sepsis, similarly lacked documentation of being offered or refusing the vaccine upon admission, despite being eligible. During interviews, the Assistant Director of Nursing (ADON) indicated a misunderstanding regarding the requirement to offer vaccinations to short-term residents and was unaware that this should be addressed at admission. The ADON stated that consents were only obtained after the surveyor's inquiry and that the facility had recently held a vaccination clinic but had not ensured all eligible residents were offered the vaccine at admission. No further evidence was provided to show that the vaccine was offered or refused by the residents at the appropriate time.
Failure to Document COVID-19 Vaccination Status for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure proper documentation of COVID-19 immunization status for three out of five residents reviewed. Specifically, the medical records for these residents did not contain any evidence that they were offered, received, or declined the COVID-19 vaccine. This lack of documentation was found despite the facility's policy requiring that each resident's medical record include information about vaccine education, administration, or refusal. The residents involved had significant medical histories, including conditions such as pulmonary embolism, pneumonia, respiratory failure, diabetes, heart failure, enterocolitis, COPD, cellulitis, and sepsis. All three residents were assessed as cognitively intact according to their Brief Interview for Mental Status (BIMS) scores. Upon review of their electronic medical records, surveyors were unable to locate any documentation regarding COVID-19 vaccination offers or decisions at the time of admission. During interviews, the Assistant Director of Nursing (ADON) indicated a misunderstanding of the requirement, believing that vaccination status did not need to be addressed for short-term residents and was unaware of the need to ask about vaccination at admission. The ADON stated that consents were only obtained after the surveyor's inquiry and that the facility was in the process of arranging another vaccination clinic. No evidence was provided to show that the residents were offered or refused the vaccine at admission prior to the surveyor's request.
Failure to Protect Residents from Abuse Due to Inadequate Supervision of Aggressive Resident
Penalty
Summary
The facility failed to protect residents from abuse when a resident with severe dementia and a history of agitation, wandering, and physical aggression was not provided with increased supervision despite escalating behaviors. This resident exhibited daily physical behaviors toward others, including hitting, kicking, and attempting to bite both staff and other residents. On the day of the incident, the resident was observed wandering into multiple resident rooms, displaying aggression, and was repeatedly redirected by staff without success. Staff interviews and progress notes documented that the resident was agitated and combative throughout the day, with multiple unsuccessful attempts to manage the behaviors. Despite the resident's known behavioral risks and a care plan that referenced interventions for redirection and monitoring, the interventions were not individualized and did not address the specific aggressive behaviors toward others. The care plan also did not include increased supervision or one-on-one monitoring, even as the resident's behaviors escalated. Staff statements confirmed that no staff member was specifically assigned to provide one-on-one supervision, and staff were unable to continuously monitor the resident due to other duties. The resident was able to access other units and resident rooms, leading to an incident where the resident entered another resident's room, resulting in a physical altercation. During the altercation, the resident entered another resident's room, and after the other resident fell, began hitting and kicking the resident on the floor. Staff responded and separated the residents, but the lack of increased supervision allowed the incident to occur. The facility's failure to implement individualized interventions and provide adequate supervision for a resident with escalating aggressive behaviors resulted in a failure to protect residents from abuse, as required by facility policy and regulatory standards.
Failure to Provide Person-Centered Care and Timely Assessment After Transfer Injury
Penalty
Summary
A deficiency occurred when a resident did not receive care and services in accordance with a comprehensive assessment, person-centered care plan, and the resident's choices. The resident, who had multiple diagnoses including Parkinson's Disease, congestive heart failure, and was on hospice care, was assessed to require an EZ-stand and assist of one for transfers. However, a Certified Nursing Assistant (CNA) transferred the resident using a pivot transfer without the EZ-stand, contrary to the care plan. Following this transfer, the resident began experiencing left knee pain, swelling, and hematoma, which was reported to nursing staff. Despite the resident's complaints of pain and visible injury, a thorough assessment including vital signs was not completed after the initial telehealth visit. Orders for pain management and comfort measures were implemented, but there was no imaging performed to rule out a fracture, and documentation shows inconsistent application of topical treatments. The resident's pain persisted, and she began refusing care, meals, and assistance. There was a lack of ongoing, comprehensive assessment and insufficient communication with the resident's physician, hospice, and responsible party regarding the change in condition and the potential need to alter the plan of care. The resident's condition continued to decline, culminating in a further change of condition that required oxygen therapy due to respiratory distress. The responsible party was not promptly notified of the incident or the resident's deteriorating status. The resident ultimately passed away, and an autopsy revealed the primary cause of death was a fracture of the distal left femur. The facility's failure to complete ongoing assessments and communicate findings to appropriate parties resulted in a finding of immediate jeopardy.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury and Death
Penalty
Summary
A deficiency occurred when a resident, who had a history of Parkinson's Disease, atherosclerotic heart disease, and was on hospice care, was transferred by a CNA using a pivot transfer with assist of one, instead of the care-planned method of using an EZ stand with assist of one. The resident's care plan and assessments clearly documented the need for the EZ stand for all transfers due to substantial/maximum assistance requirements. Despite this, the CNA deviated from the care plan and performed a manual pivot transfer. Following this transfer, the resident complained of severe left knee pain, with swelling and bruising observed. The resident reported to multiple staff members that the EZ stand was not used and that she was dropped during the transfer, with her knee hitting the ground. Facility documentation and staff statements revealed inconsistencies and a lack of clear communication regarding the incident. Initial nursing notes did not document a fall or injury, and the incident was not immediately reported as a fall to hospice or the responsible party. The resident's condition deteriorated over the following days, with increased pain, swelling, and cognitive decline. Family members were not promptly informed of the incident or the resident's change in condition. The facility's investigation was delayed, and there was confusion among staff regarding the events that led to the injury. The responsible party only learned of the incident after observing the resident's decline and inquiring with staff. An autopsy determined that the resident suffered a fracture of the left distal femur related to the transfer, which was identified as the cause of death. The medical examiner concluded that the injury was consistent with a fall or being dropped, rather than a soft tissue injury or minor trauma. The facility failed to ensure adequate supervision and adherence to the resident's care plan, resulting in an accident hazard and a lack of appropriate intervention to prevent the injury and subsequent death.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet the needs of all residents, as required by its own Facility Assessment. Interviews with residents revealed that they experienced significant delays in response to call lights, with some reporting wait times of up to an hour or more, particularly during busy periods such as mealtimes or when staff levels were low. One resident, who requires a Hoyer lift and assistance from two staff members for transfers, reported being the last to receive morning care and experiencing longer wait times when staffing was inadequate. Another resident, who is dependent on continuous oxygen, expressed concern about not receiving timely assistance, especially during dinner hours, and described the situation as distressing. Staff interviews corroborated these concerns, with multiple staff members indicating that staffing shortages were particularly acute on weekends due to frequent call-ins. Staff described being pulled in multiple directions, struggling to complete all required tasks and documentation within their shifts, and sometimes needing to stay late or finish charting the next day. One LPN noted that the staffing goal was not always met and suggested that having a dedicated admission nurse would alleviate some of the workload. The staff scheduler confirmed that staffing was based on the Facility Assessment and resident acuity, but also acknowledged that the number of staff scheduled did not always meet the identified requirements, and that medication technicians (MTs) were counted as CNAs on the schedule, despite not being listed in the Facility Assessment. A review of staffing schedules for the month of February showed that the facility was consistently short of the required number of licensed nurses and CNAs as outlined in the Facility Assessment. On numerous days, the facility was down by one or more licensed nurses and several CNAs, with the shortfalls ranging from half a CNA to as many as five and a half CNAs on certain days. These staffing deficits were confirmed by both the staff scheduler and facility leadership during interviews. The surveyor concluded that the facility did not provide staffing levels that met its own identified needs, as documented in the Facility Assessment, and that both residents and staff expressed ongoing concerns about inadequate staffing.
Failure to Report and Investigate Injury Following Incorrect Transfer
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, or injuries of unknown origin for a resident who experienced significant harm following an incorrect transfer. The resident, who had Parkinson's Disease and required an EZ stand with one-person assist for transfers, reported severe left knee pain after being transferred by a method not consistent with her care plan. The pain began after a pivot transfer was performed instead of using the required EZ stand, and the resident subsequently developed bruising, swelling, and was later found to have a left distal femur fracture. Despite the resident's complaints and the visible signs of injury, the facility did not report the incident to the Nursing Home Administrator or the State Agency as required by their abuse prevention policy. The facility's own policy mandates immediate reporting of any suspicion of abuse or serious bodily injury, including injuries resulting from failure to follow the care plan. However, the incident was not entered into the facility's grievance log or reported as a Facility Reported Incident (FRI) to the state, even though several staff members were aware of the situation soon after it occurred. Interviews with facility leadership revealed that the decision not to report was based on an abuse reporting algorithm intended for assisted living facilities, not skilled nursing facilities. The administration did not consider the incident to meet the criteria for willful intent, despite the resident's injury and subsequent death. The facility's investigation was delayed, and conflicting accounts from staff and the resident were cited as reasons for not reporting. The failure to follow the resident's care plan and the lack of timely reporting to the appropriate authorities constituted a violation of the facility's abuse prevention and reporting policies.
Failure to Timely Report Suspected Neglect and Injury of Unknown Origin
Penalty
Summary
A resident with Parkinson's Disease and a history of myocardial infarction was assessed to require an EZ stand and assist of one for transfers, as documented in the care plan. Despite this, the resident was transferred using a pivot transfer by a single staff member, contrary to the care plan instructions. Following this transfer, the resident complained of pain, swelling, and bruising to the left knee, which she reported began after being transferred without the EZ stand. The resident's condition declined both physically and cognitively after the incident, and she subsequently passed away at the facility. The facility's own policy requires immediate reporting of any suspected abuse, neglect, or injury of unknown origin to the Nursing Home Administrator and the State Agency, with specific timelines for reporting based on the severity of the injury. Despite multiple staff being aware of the resident's complaints, bruising, and decline, the incident was not reported to the administrator or the State Agency within the required timeframe. The responsible party for the resident expressed concerns to the facility, believing the resident had been dropped during the transfer, but these concerns were not communicated to the appropriate authorities as required. Interviews and record reviews revealed that the facility did not initiate a Facility Reported Incident (FRI) related to the transfer without the EZ stand, nor did they notify the State Agency. The Nursing Home Administrator stated that the incident was not reported because the facility followed an abuse reporting algorithm that did not consider the event as meeting the criteria for willful intent. However, surveyors noted that the algorithm used was not appropriate for skilled nursing facilities. The medical examiner's preliminary autopsy results indicated the cause of death was a fracture of the distal left femur, consistent with a fall or drop, further highlighting the failure to report the incident as required by policy and regulation.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician or physician extender at the required intervals, as outlined in their own policy and federal regulations. For one resident, there was only a single documented physician visit since admission, with all other visits conducted by nurse practitioners, and no evidence of alternating visits between the physician and physician extender. The facility was unable to provide documentation of additional physician visits or an explanation for the lack of alternating visits. Another resident was not seen by a physician within the required 60-day interval following the initial 90 days after admission. There was a gap of 128 days between physician visits, and after the most recent documented physician visit, there was another gap of 114 days without a physician assessment. The deficiency was identified through record review and confirmed in interviews with the Nursing Home Administrator and Director of Nursing, who were unable to provide additional documentation to support compliance with physician visit requirements.
Inadequate Supervision and Care Planning Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R3 and R2. R3, who has multiple medical conditions including multiple sclerosis and paraplegia, experienced a fall while receiving incontinent care from a CNA. The CNA reportedly guided R3 out of bed, but R3 stated that the CNA watched her roll out of bed, resulting in a laceration to the forehead and a right femur fracture. The facility did not conduct a thorough investigation into the incident, as there were no statements from the nurse who assessed R3 or from R3 herself, and no details about the bed's position or whether care plan interventions were in place at the time of the fall. Additionally, R3's care plan did not address the air mattress on the bed. R2, who has a history of cerebral infarction and is severely cognitively impaired, sustained multiple falls, one of which resulted in injury. The facility did not complete thorough investigations after each fall to determine the root cause. Some interventions established were not specific enough to prevent further falls. R2's care plan included interventions such as offering to be in common areas while awake and monitoring for changes in the ability to navigate the environment, but there was no documentation indicating whether these interventions were implemented or effective. The facility's policy on fall management requires assessing hazards and risks, developing a care plan to address these, and implementing appropriate interventions. However, the facility failed to adhere to this policy, as evidenced by the lack of thorough investigations and specific interventions for both R3 and R2. The deficiencies in supervision and care planning contributed to the accidents and injuries sustained by the residents.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff was provided to meet the needs of all residents, affecting their ability to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Surveyors observed and recorded multiple instances of inadequate staffing levels, which were corroborated by interviews with residents and staff. Residents reported long wait times for call lights to be answered, with some waiting up to an hour or more. Staff members, including CNAs and LPNs, expressed concerns about being unable to complete their duties due to insufficient staffing, particularly on weekends and nights. Specific examples include a resident who reported having to wait 45 minutes to an hour for call lights to be answered and another resident who was not walked as required due to staff shortages. A CNA reported having to come in early to complete tasks and sometimes leaving essential duties unfinished. The facility's call light system showed delays in response times, with one instance of a call light not being answered for 25 minutes. Residents also reported that their concerns about staffing had been raised in Resident Council meetings but remained unaddressed. The facility's staffing records revealed that the number of CNAs on duty frequently fell short of the facility's assessed needs. For example, during a three-day period in October, the facility was consistently understaffed by three to five CNAs. This pattern continued throughout November, with the facility failing to meet staffing requirements on 17 out of 30 days. The Scheduling Coordinator confirmed that staffing was based on acuity and census, but acknowledged challenges in maintaining appropriate levels, particularly on weekends due to call-ins and the lack of incentive programs for staff retention.
Inconsistent Water Distribution to Residents
Penalty
Summary
The facility failed to ensure that water was consistently provided to residents, as required by their policy. The policy, dated September 2020, mandates that clean water pitchers or cups be filled with ice and water every shift and as necessary, with specific instructions for residents on thickened liquids or fluid restrictions. However, multiple residents reported that they only received water upon request, and some did not receive it at all. Observations by the surveyor confirmed the absence of water glasses in some residents' rooms, and staff interviews revealed inconsistencies in water distribution practices across different units. Several residents, including those with cognitive impairments, were affected by this deficiency. For instance, a resident with a BIMS score indicating severe cognitive impairment did not have a water glass in their room and reported not receiving water. Other residents, who were cognitively intact, also reported that water was not provided unless requested. Staff members provided varying accounts of water distribution, with some stating that water was passed out only when possible, and others indicating a lack of necessary supplies like cups. The Director of Nursing and other administrative staff were informed of these findings, but no explanation was provided for the inconsistency in water distribution.
Failure to Investigate Alleged Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation of mistreatment involving a resident, identified as R1, who reported being yelled at and handled roughly by a Certified Nursing Assistant (CNA). The facility's policy mandates prompt and aggressive investigation of all reports and allegations of mistreatment, but in this case, there was no evidence of a formal investigation being conducted. The Assistant Administrator (AA-E) acknowledged being informed by R1's family member about the alleged mistreatment but did not document any investigation or take formal steps to address the issue. R1, who had moderate cognitive impairment and multiple medical conditions including hemiplegia, diabetes, and epilepsy, was admitted to the facility and later discharged. During the survey, R1's family member reported to the surveyor that a CNA was rough and yelled at R1, and this was communicated to AA-E. However, AA-E did not recall any specific details about the alleged mistreatment and only provided a verbal warning to the CNA without documenting the incident or conducting a formal investigation. The surveyor's review of the facility's grievance report revealed no documentation of the alleged mistreatment, except for a separate grievance about a missing phone. Despite being informed of the allegations, AA-E did not initiate a formal investigation or document any actions taken to address the concerns. The lack of documentation and formal investigation into the alleged mistreatment constitutes a deficiency in the facility's compliance with its abuse policy.
Failure to Ensure Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications ordered on an as-needed (PRN) basis. Specifically, a resident with multiple medical conditions, including multiple sclerosis, diabetes mellitus, and anxiety disorder, was prescribed Lorazepam 0.5 mg every four hours PRN for anxiety without an end date. This prescription was noted upon the resident's readmission to the facility, as documented in the hospital discharge papers dated 11/10/24. Upon review of the resident's physician orders on 12/2/24, the surveyor found that the order for Lorazepam did not include an end date. When questioned, the Med Tech indicated that RNs were responsible for ensuring stop dates for PRN psychotropic medications. The Director of Nursing (DON) later confirmed that the nurse who enters the order is responsible for including the stop date. The surveyor noted that an end date was added to the order on 12/2/24 by the Regional Nurse Consultant, following the surveyor's initial review.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, Oxycodone 5mg, as ordered by the physician on multiple occasions. The resident, who has a history of chronic pain syndrome, polyosteoarthritis, and anxiety disorder, was prescribed Oxycodone to manage pain related to a wedge compression fracture. Despite the facility's policy requiring medications to be reordered in advance to prevent lapses in therapy, the resident did not receive the medication on several dates across July, September, October, and November 2024. The deficiency was attributed to a breakdown in the medication reordering process. Nursing staff were responsible for reordering medications when a two-day supply remained, but there were instances where the medication was not available due to issues with obtaining a new prescription from the nurse practitioner. The facility's electronic medication administration record (eMAR) and nurses' notes documented multiple instances where the medication was unavailable, pending delivery, or awaiting authorization from the nurse practitioner. The resident reported experiencing significant pain when the medication was not administered, rating it as "off the chart." Interviews with facility staff, including registered nurses, licensed practical nurses, and the Director of Nursing, revealed that there were challenges in obtaining timely prescriptions for narcotic medications. Staff indicated that they attempted to reorder medications and contact the nurse practitioner for new prescriptions, but there were delays and uncertainties in the process. The Director of Nursing acknowledged the struggle in obtaining scripts and noted that the facility was dependent on the nurse practitioner or medical doctor to provide the necessary prescriptions.
Failure to Consult Physician After Resident's Significant Condition Changes
Penalty
Summary
The facility failed to promptly consult with the resident's physician when a resident (R414) experienced significant changes in condition following unwitnessed falls on 10/27/23 and 10/29/23. Despite signs consistent with a head injury, including altered mentation, pain, vomiting, and cognitive impairment, the facility did not seek guidance from the resident's primary physician, the Medical Director, or the Hospice provider. The resident's condition continued to deteriorate, leading to his eventual passing. The facility's policy on Change in Condition clearly outlines the procedures for notifying physicians and responsible parties of any changes in a resident's condition, which were not followed in this case. The resident, R414, had a complex medical history upon admission, including dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, and failure to thrive. R414 required extensive assistance with daily activities and was at high risk for falls due to limited mobility and impaired balance. Despite being under hospice care for Monoclonal Gammopathy, the facility did not appropriately address the significant changes in R414's condition that were unrelated to his hospice diagnosis. The staff failed to recognize the urgency of the situation and did not escalate the matter to the resident's physician in a timely manner. Throughout the documented incidents, including R414's complaints of pain, altered mentation, weakness, and other concerning symptoms, there was a lack of communication and coordination between the facility staff, hospice provider, and the resident's physician. The facility's failure to involve the physician in assessing and managing R414's changing condition, especially after the falls and head injury, resulted in a delay in appropriate medical intervention. The staff's reliance on hospice directives without consulting the physician directly contributed to the inadequate response to R414's deteriorating health status.
Deficiency in Fall Prevention and Post-Fall Protocols
Penalty
Summary
The report highlights a concerning deficiency in a nursing home's care related to the prevention of accidents and falls, particularly in the case of resident R414. R414, admitted with multiple diagnoses including dementia and anxiety, was assessed as high risk for falls upon admission. Despite this risk assessment, the facility failed to prevent two unwitnessed falls that resulted in significant injuries to R414, including head trauma and cognitive impairment. The facility's lack of post-fall investigations after each incident and failure to revise the care plan to address the identified risks contributed to the ongoing hazards faced by R414. The first fall occurred when R414 was found on the bathroom floor with altered mentation and an inability to orient himself. Subsequent falls included reaching for a call light that was out of reach, leading to head injuries and cognitive changes. The report notes a lack of proper documentation and notification to the medical team regarding R414's changing condition, including signs of weakness, altered speech, and cognitive decline. Despite the facility's policies outlining fall prevention measures and post-fall protocols, these were not effectively implemented in R414's case, resulting in repeated incidents and ultimately, R414's passing.
Communication and Coordination Gaps in Resident Care Management
Penalty
Summary
The deficiency identified in the report revolves around the facility's failure to ensure proper collaboration and communication processes between hospice, the facility, the physician, and the power of attorney for a resident (referred to as R414) with multiple complex medical conditions. R414 experienced significant changes in condition, including unwitnessed falls, altered mentation, slurred speech, weakness, and other concerning symptoms. Despite these changes, there were lapses in updating the physician, power of attorney, and ensuring coordination of care between hospice and the facility. The facility staff did not consistently relay critical information about R414's condition, leading to a lack of comprehensive care planning and decision-making. The report highlights instances where the facility did not adequately inform hospice, the physician, or the power of attorney about R414's deteriorating condition, such as head injuries, altered mentation, and physical decline. There were delays in notifying the appropriate parties about significant changes, including falls and cognitive impairments, which impacted the continuity of care and decision-making processes. The lack of timely and accurate communication between the facility, hospice, and other involved parties resulted in a failure to address R414's evolving care needs effectively.
Failure to Monitor Skin Under Immobilizer Leads to Stage 4 Pressure Ulcer
Penalty
Summary
The facility did not ensure they provided the necessary care, consistent with professional standards of practice, to prevent the development of pressure ulcers for a resident who was at high risk. The resident returned to the facility following surgical repair to the left knee and was required to wear an immobilizer for six weeks. The facility failed to monitor the resident's skin under the immobilizer, leading to the development of a stage 4 pressure ulcer on the back of the left lower leg. The resident had a history of multiple medical conditions, including a recent surgery, decreased mobility, and a need for staff assistance with activities of daily living. Despite the hospital discharge instructions and physician orders, the facility did not conduct regular skin assessments under the immobilizer. The Director of Nursing confirmed that nursing staff should have been checking the skin each shift, but there was no documentation to support that these checks were being performed. The pressure ulcer was discovered during a random skin check by the Director of Nursing, not by the regular staff. The facility's assessment indicated that the pressure ulcer was unavoidable due to the non-removable brace, but this was contradicted by the fact that staff were reportedly washing and applying lotion to the area. The facility's documentation did not clarify whether the immobilizer was removed during skin checks, and there was no evidence that the physician's order regarding skin checks under the immobilizer was clarified.
Infection Control Deficiencies
Penalty
Summary
The facility did not ensure all staff exposed to COVID-19 were properly fit tested for an N95 mask to prevent the spread of infection. Upon entering the facility for the Recertification and Complaint Survey, the surveyor identified a resident with COVID-19 and observed that not all staff were up to date with their N95 fit testing. The facility was behind on fit testing and did not have a clear record of which staff were currently up to date. Despite the facility's efforts to fit test staff annually in March, only 10 out of 30 staff members who worked with COVID-positive residents were up to date on their fit testing at the time of the survey. The facility's plan to fit test staff when they come to pick up paychecks was noted, but it was clear that the current fit testing status was inadequate for infection control purposes. The facility's policy required staff to wear full PPE, including N95 respirators, when providing care to COVID-positive residents, but this was not consistently enforced due to the lapse in fit testing. The surveyor's review of the facility's infection control program and interviews with staff revealed that the facility was aware of the issue but had not yet resolved it effectively. The facility's failure to ensure proper fit testing for all staff exposed to COVID-19 posed a risk of infection spread among residents and staff. Additionally, the facility did not maintain a sanitary environment for a resident with a Foley catheter. The surveyor observed the resident's catheter bag and tubing laying on the floor under the wheelchair and being dragged during transport. The facility's policy on indwelling catheters required the catheter bag to be kept off the floor and covered during transport, but this was not followed. The resident's medical record did not contain a comprehensive plan of care for the indwelling catheter, and staff interviews confirmed that the catheter bag should not touch the floor. The facility's failure to maintain the catheter bag in a sanitary manner increased the risk of infection for the resident. The surveyor's observations and interviews with staff highlighted the facility's deficiencies in infection prevention and control, both in terms of N95 mask fit testing and Foley catheter maintenance. These deficiencies were documented and shared with the facility's administration during the survey process.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility did not ensure residents received the required written notice information related to their transfers out of the facility. This deficiency was observed in seven residents who were transferred to the hospital. The required transfer notice, which should include information on appeal rights, the contact details of the State Long-Term Care Ombudsman, and other relevant agencies, was not provided to any of these residents. The Assistant Nursing Home Administrator (ANHA) was unaware of the full notice requirements and indicated that the facility was in the process of updating their forms and policies to comply with these requirements. However, at the time of the survey, the facility did not have a policy and procedure related to the transfer notice requirement in place. For instance, one resident (R108) was transferred to the hospital after a fall and subsequently chose not to return to the facility. The medical record did not contain evidence that the resident received the required written notice information with their transfer. Similarly, another resident (R38) was transferred to the hospital twice due to medical conditions, but the transfer forms provided did not include information on how to appeal the transfer or contact details for the Ombudsman. The facility's Assistant Nursing Home Administrator confirmed that the bed-hold form used was outdated and did not include the necessary information. Other residents, such as R25, R77, R54, R85, and R65, also did not receive the required transfer notices with the necessary information. The facility was unable to provide evidence that these notices were given, and the forms used lacked critical details such as appeal rights and contact information for relevant agencies. Despite the facility's acknowledgment of the issue and ongoing efforts to update their forms, the deficiency remained unaddressed at the time of the survey, as evidenced by the lack of proper documentation in the residents' medical records.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility did not ensure that an allegation of an injury of unknown source for a resident was reported immediately to the State Survey Agency within the required 2-hour timeframe. The resident experienced pain in the left knee, and an X-ray revealed a left distal femur fracture. Despite the severity of the injury, the facility failed to report the injury within the mandated timeframe and did not submit the results of their investigation within 5 working days as required by policy. The resident, who has a history of epilepsy, muscle weakness, anxiety disorder, dysphagia, history of falling, and hemiplegia, was seen by a Nurse Practitioner for routine maintenance and complained of left knee pain. An X-ray was ordered, and the results indicated a fracture. The resident was subsequently admitted to the hospital for surgical repair. The Director of Nursing (DON) was unable to provide evidence that the injury was pathological and did not report the injury to the State Survey Agency, believing it was unnecessary. Further review of the resident's medical and hospital records showed no documentation supporting the claim that the fracture was pathological. The DON admitted to not submitting a self-report investigation and was unable to locate staff statements regarding the incident. The lack of documentation and timely reporting indicates a failure to comply with regulatory requirements for reporting and investigating injuries of unknown sources.
Lack of Individualized Comprehensive Care Plans
Penalty
Summary
The facility did not ensure that residents had individualized comprehensive care plans. This deficiency was observed in two residents out of 23 reviewed. Resident 85 was admitted with an indwelling catheter but did not have a comprehensive care plan addressing catheter care. Despite the presence of physician orders for catheter management, the resident's medical records lacked a care plan for bowel and bladder care or indwelling catheter care. Interviews with the RN, Resident Care Coordinator, and DON confirmed that the care plan should have included these interventions, but it was an oversight during the review of hospital discharge paperwork and subsequent care plan updates. Resident 81 was admitted with a diagnosis that included the use of anticoagulant medication. However, there was no comprehensive care plan with individualized interventions to monitor the anticoagulant therapy. The resident's medical records showed that a care plan for anticoagulant use was initiated and resolved on the same day, leaving no active care plan for ongoing monitoring. Interviews with the Resident Care Coordinator and DON confirmed that an anticoagulant therapy care plan should have been included but was missed due to a transition in staff responsibilities. The surveyor shared concerns with the Nursing Home Administrator, DON, and Assistant Nursing Home Administrator regarding the lack of appropriate care plans for both residents. No additional information was provided by the facility to address these concerns.
Failure to Ensure Urology Follow-Up for Resident with Indwelling Catheter
Penalty
Summary
The facility did not ensure that a resident with an indwelling catheter received the necessary consult services. The resident, who was initially admitted without an indwelling catheter, was hospitalized due to a change in condition and returned with a catheter due to urinary retention. Despite hospital discharge instructions to follow up with urology for a voiding trial, the facility failed to arrange this follow-up. The resident's nurse practitioner's notes indicated multiple failed voiding trials and the need for a urology consult, but no documentation was found to confirm that this follow-up occurred. The Assistant Director of Nurses confirmed that the urology referral was canceled due to a subsequent hospital stay, and no new referral was requested by the facility. The surveyor observed the resident with an indwelling catheter and noted that the resident was unaware of the reason for its use. The facility's policy required assessment for catheter removal as soon as possible, but this was not adhered to. The Director of Nursing incorrectly stated that the resident was admitted with the catheter, despite documentation showing otherwise. The surveyor's findings highlighted a lack of proper follow-up and communication regarding the resident's catheter management, leading to the deficiency noted in the report.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility did not ensure that a resident (R82) was properly assessed for the use of bed rails, nor did it have evidence that the risks and benefits were discussed with the resident or their representative. R82 was admitted for short-term rehabilitation with multiple diagnoses, including severe cognitive impairment and physical disabilities. Despite an assessment indicating that side rails were not appropriate for R82, the resident's bed was observed to have fixed grab bars, which are considered side rails. The facility's policy requires a side rail assessment upon admission, readmission, significant change, and annually, but this was not adhered to in R82's case. Interviews with facility staff revealed inconsistencies in the communication and documentation of side rail assessments. The Assistant Director of Nursing (ADON) confirmed that enabler bars are considered side rails and that assessments are typically completed by floor nurses. However, there was no clear process for communicating the results of these assessments. The Therapy Director stated that therapy did not recommend side rails for R82, and the Building Manager could not verify when the enabler bars were installed or removed. The grab bars were eventually removed from R82's bed, but this action was not documented or communicated effectively, highlighting a lapse in the facility's adherence to its own policies and procedures.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being. Residents voiced concerns about insufficient staff to care for their needs, and the facility was identified as having consistently low weekend staffing on the Staffing Data Report submitted to CMS from October 1, 2023, through December 31, 2023. Staff also indicated there were not enough staff on the unit to assist with residents' cares and needs. The facility's algorithm for determining the number of CNAs needed based on total census was not met on multiple occasions, leading to a shortage of CNAs on various days in December 2023, as documented by the surveyor's review of the daily staffing schedules and resident council notes. The facility's daily staffing schedule often fell short of the required number of CNAs as per their algorithm. For example, on December 31, 2023, with a census of 114 residents, the facility was short by 7 CNAs. Similar shortages were noted on other days, such as December 30, 2023, December 24, 2023, December 23, 2023, December 17, 2023, and December 16, 2023. The Scheduling Coordinator confirmed that the facility struggled with low weekend staffing and did not always meet the required number of CNAs. Additionally, the acuity of the residents was not considered when calculating the staffing needs, further exacerbating the issue. Residents consistently expressed concerns about low staffing during resident council meetings, and staff reported that low staffing was an ongoing issue. The surveyor observed a resident's call light active for 15 minutes, indicating delayed response times due to insufficient staffing. The facility's performance improvement plan (PIP) to address low staffing concerns was reviewed, but it lacked specific start or completion dates for most action items, indicating a lack of urgency in addressing the staffing deficiencies.
Failure to Ensure Proper Use and Documentation of Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents were not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. For Resident 25, the facility failed to implement a gradual dose reduction (GDR) for Mirtazapine, an antidepressant medication, despite recommendations from the pharmacist and behavior management team. The resident's Power of Attorney (POA) declined the GDR, and the facility did not document the refusal properly or attempt another GDR within the required timeframe. Additionally, a progress note from the Nurse Practitioner (NP) recommending the continuation of the current dose was not found in the resident's medical record, raising concerns about documentation practices and adherence to GDR protocols. Resident 103 was prescribed PRN Lorazepam, a sedative/antianxiety medication, without a documented rationale from the physician to extend its use beyond 14 days. The resident's care plan included the use of Lorazepam as part of a hospice comfort care package, but the PRN order did not have a stop date, violating regulations that limit PRN use of psychotropic drugs to 14 days. The issue was only addressed after the surveyor raised concerns, and a new order was entered with a 14-day limit. Resident 81 was prescribed Primidone, an anticonvulsant, without a clear indication of use. The medication administration record (MAR) incorrectly listed seizures as the reason for the prescription, despite the resident not having a diagnosis of seizures. Upon review, it was clarified that the resident was taking Primidone for essential tremors, and the order was subsequently modified. This discrepancy highlights issues with accurate documentation and the need for proper diagnosis alignment with prescribed medications.
Failure to Display Required Information
Penalty
Summary
The facility did not ensure the required posted information was displayed in the main entrance, lobby area, and all six units, potentially affecting all 117 residents. The missing information included a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. Additionally, there was no statement indicating that residents may file a complaint with the State Survey Agency concerning any suspected violations of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property, and non-compliance with advanced directives. On multiple occasions, the surveyor observed the absence of the required postings in the main entrance, lobby area, and all six units. When interviewed, the Assistant Nursing Home Administrator and the Administrator were unaware that the postings were missing. The Director of Nurses suggested that the postings might have been removed due to remodeling. The Nursing Home Administrator later provided a sheet of paper with the required postings, but it contained incorrect information and lacked the necessary statements related to complaints, abuse, advanced directives, and the correct State Agency office. The Nursing Home Administrator acknowledged the issue and indicated they were working on it.
Latest citations in Wisconsin
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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