Amethyst Health Of Wausau
Inspection history, citations, penalties and survey trends for this long-term care facility in Wausau, Wisconsin.
- Location
- 1010 E Wausau Ave, Wausau, Wisconsin 54403
- CMS Provider Number
- 525405
- Inspections on file
- 38
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 37 (4 serious)
Citation history
Health deficiencies cited at Amethyst Health Of Wausau during CMS and state inspections, most recent first.
Multiple residents experienced misappropriation of their funds when payments intended for their care were deposited into an unauthorized account controlled solely by a business office manager, who used the funds for personal expenses. Families and residents reported ongoing issues with missing payments, unexplained billing, and inability to access their money, while facility staff failed to promptly investigate or report these concerns, leaving residents at risk of financial exploitation.
A facility failed to promptly report suspected misappropriation and exploitation of resident funds to authorities after discovering unauthorized withdrawals and questionable account activity managed by a business office manager. Multiple residents and their families experienced unexplained billing issues, missing payments, and depleted accounts, while staff concerns and evidence of possible forgery were not reported as required. The deficiency resulted in a finding of immediate jeopardy.
The facility did not thoroughly investigate multiple allegations of misappropriation and exploitation of resident funds, despite evidence of suspicious financial activity and concerns raised by residents, families, and staff. Key staff were aware of the issues but were directed not to report them to authorities or conduct a full investigation, resulting in continued financial discrepancies and lack of protection for affected residents.
Facility administration failed to implement effective systems for managing resident finances, resulting in unmonitored accounts, unauthorized withdrawals, and inaccurate billing. A business office manager maintained a hidden account used for various purchases and withdrawals, while residents and their families experienced missing receipts, unexplained balances, and continued withdrawals after discharge. The administration did not follow required reporting or investigation procedures for suspected misappropriation, and necessary policies and tools were lacking.
A registered nurse was hired without the required background checks, including the Background Information Disclosure, Department of Justice response, and Government Findings report, as mandated by facility policy. Review of personnel files and staff interviews confirmed that these checks were not completed prior to the nurse starting work, and several other staff files were also found to be missing required documentation.
A resident was re-admitted after hospitalization and removal of an indwelling catheter, but staff did not complete or document comprehensive assessments or monitoring as required by professional standards. Facility leadership confirmed there was no current policy on assessments and documentation, and acknowledged the resident was not appropriately assessed or monitored after re-admission.
Two housekeeping staff members did not receive mandatory infection control training since hire, as confirmed by staff interviews and record review. The NHA acknowledged the absence of a policy and documentation for such training, potentially affecting all residents.
Three residents who were either discharged or deceased had open trust fund accounts with remaining balances that were not returned to them or their representatives within the required 30-day period. The facility lacked a policy for timely return of these funds, and the issue was confirmed through record review and staff interview.
A resident with severe cognitive impairment was identified as an elopement risk and fitted with a Wander Guard device, despite the most recent risk assessment indicating no elopement risk. The device was applied without a physician's order or written consent, and only verbal consent was obtained from the resident's POA. Staff confirmed that no updated risk assessment or proper documentation was completed prior to the use of the Wander Guard.
A resident with an unstageable pressure ulcer and a history of diabetes repeatedly refused wound care treatments, dressing changes, and compliance with repositioning protocols. Although these refusals were documented in nursing notes, the care plan was not updated to reflect the resident's choices or the facility's response, contrary to facility policy.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with stage four pressure injuries had a dressing change performed by an LPN who failed to keep clean and dirty areas separate on the barrier and brought the treatment cart into the room, contrary to facility expectations. Another resident with a suprapubic catheter was observed with the drainage bag touching the floor on two occasions, despite staff acknowledging that this practice does not meet infection control standards.
A resident admitted with a stage 2 sacral pressure ulcer did not receive a comprehensive skin assessment upon admission. Instead, an LPN performed only a basic assessment, missing the sacral wound, and a full assessment by an RN was delayed for two days. This resulted in a lack of documentation to track the pressure injury's progression.
A resident requiring close supervision while eating was left unattended with food, contrary to care plan and speech therapy recommendations. An LPN left the resident alone after administering medication, assuming a CNA would assist shortly. The CNA later expressed surprise at the lack of supervision, indicating a communication lapse. Interviews confirmed the need for supervision to prevent choking, highlighting a failure in protocol adherence.
A resident experienced inadequate pain management due to inconsistent pain assessments and a lack of individualized care planning. Despite reporting significant pain in the legs and back, the resident's care plan only mentioned migraines and did not include scheduled pain medications or non-pharmacological interventions. Interviews with staff revealed communication gaps and an inability to adjust the pain management plan, leading to unmet pain needs.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a Kennedy terminal ulcer. A CNA was observed performing personal care without a gown, despite EBP signage on the door. The CNA misunderstood the need for EBP due to a communication lapse during the morning report. The DON confirmed EBP was reinstated after the wound reopened, but this was not communicated to staff, leading to the deficiency.
The facility failed to establish a governing body responsible for implementing policies, leading to significant financial arrears affecting resident care. Various service providers have ceased services due to unpaid invoices, and financial concerns are not regularly discussed in meetings. The facility is transitioning to a new financial management service.
Failure to Prevent and Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that residents were free from misappropriation and exploitation of their funds. Multiple instances were identified where resident payments intended for care and room charges were deposited into a bank account that only the Business Office Manager (BOM) had access to. This account was unknown to other facility leadership and was used for personal purchases, including cash withdrawals, restaurant, and store charges. The BOM was the sole authorized user of this account, and the facility administrator only became aware of its existence after reviewing a bank statement. The administrator's subsequent investigation revealed that resident checks and insurance payments were being deposited into this unauthorized account, and the BOM closed the account after being questioned. Several residents and their families reported ongoing issues with missing funds, unexplained billing, and inability to access or account for their money. For example, one resident's family continued to receive bills despite having made substantial payments, and another resident was at risk of losing their place at an assisted living facility due to missing Social Security payments. In some cases, checks written from residents' personal checkbooks had signatures that did not match the residents' handwriting, and funds were withdrawn from resident accounts after discharge. Facility staff, including the social worker and administrator, expressed concerns about the whereabouts of resident funds and suspected misappropriation, but these concerns were not promptly or thoroughly investigated or reported to the state agency or law enforcement as required. The facility did not have or could not provide policies related to accounts receivable or resident funds when requested by the surveyor. Interviews with staff and family members revealed a lack of communication and transparency regarding the handling of resident funds. The administrator and other leaders failed to notify affected residents or their representatives about the suspected misappropriation, and there was no evidence of a thorough internal investigation prior to the survey. The facility's failure to act on suspicions of misappropriation and to report these incidents in a timely manner left residents at continued risk of financial exploitation and resulted in a finding of immediate jeopardy.
Removal Plan
- The NHA and member of a governing body conducted an audit of past residents' funds. Credits will be made to families who are owed. The NHA and member of the governing body reviewed the petty cash policy and implemented it.
- The Director of Nursing (DON), Social Service Director (SSD) and Minimum Data Set (MDS) nurse/care plan nurse will review clinical documents to identify any negative outcome that may have resulted from the alleged deficiency. The following documents were reviewed: NAR report, 24-hour summary, order report listing, incident report portal, transfer/discharge log, concern log and resident council minutes.
- The DON/SSD/Nurses will complete assessment of all residents to identify any negative psychosocial outcomes or worsening of overall condition that may have resulted from the alleged deficiency. The attending physician/Nurse Practitioner (NP) of the resident will be notified of any negative findings.
- The NHA/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA/SSD/DON will interview the resident representatives.
- The corporate BOM will also audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified.
- Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.
Failure to Report Suspected Misappropriation and Exploitation of Resident Funds
Penalty
Summary
The facility failed to immediately report suspected misappropriation and exploitation of resident funds to the State Agency and local authorities upon discovery. The Nursing Home Administrator (NHA) identified concerns after reviewing a bank statement for an account under the facility's name, which was unknown to the NHA. The statement revealed significant cash withdrawals and a money order, and the bank confirmed that the Business Office Manager (BOM) had a checkbook and debit card for this account. The NHA suspected that resident payments intended for care and room fees were being deposited into this unauthorized account rather than the facility's Resident Fund Management System. Despite these findings, the NHA was instructed by the Director of Operations (DOO) not to report the concerns to the State Agency or police department. Multiple residents were affected by these actions. For example, one resident's family reported ongoing billing issues despite making substantial payments, and another resident's family was unable to determine the whereabouts of Social Security income. The Social Worker and NHA also expressed concerns about residents with significant funds who suddenly had negative balances or depleted accounts, and there were suspicions of forged signatures on personal checks. An insurance check was also deposited into the unauthorized account, with no clear indication of which resident it was intended for. These concerns were not reported to the appropriate authorities as required by facility policy and federal regulations. Interviews with staff and family members confirmed ongoing concerns about the handling of resident funds, lack of transparency, and the absence of timely reporting to authorities. The BOM resigned after a disciplinary meeting, and the NHA eventually contacted the police and State Agency only after being prompted by the surveyor. The facility was unable to provide policies for accounts receivable and payable when requested by the surveyor, and the failure to report the suspected misappropriation and exploitation of resident funds resulted in a finding of immediate jeopardy.
Removal Plan
- The DON/SSD/Nurses will complete assessment of all residents to identify any negative psychosocial outcomes or worsening of overall condition that may have resulted from the alleged deficiency. The attending physician/NP of the resident will be notified of any negative findings.
- The NHA/SSD/DON will conduct interviews of interviewable residents to identify if they have any concern related to mishandling, misused and/or misappropriation of their funds. Any identified concern will be reported to the state agency and law enforcement, and investigation will be conducted. For residents who are not able to participate in the interviews, the NHA/SSD/DON will interview the resident representatives.
- The corporate business office manager will audit all residents' status of benefits (Medicaid and Managed Care) to identify any concern. An investigation will be conducted if any concern is identified. Any identified misappropriation of residents' funds and exploitation will be reported to the NHA, state agency and law enforcement.
- The NHA/DON will provide training to the department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) related to the intent of F609, facility policy related to Abuse, Neglect, Exploitation and Misappropriation, focusing on the reporting requirements and responsibility of the staff to misappropriation of resident property, and exploitation to the state agency and police department.
- The DON/NHA/trained department head will provide training to all staff about reporting allegations of abuse, neglect and misappropriation to the Administrator/DON. The staff members who are not available will receive their education prior to starting their shift upon return to work.
Failure to Investigate Alleged Misappropriation and Exploitation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of misappropriation and exploitation of resident funds, affecting at least five residents. The Nursing Home Administrator (NHA) discovered a bank account under the facility's name, which was unknown to them, containing suspicious withdrawals and transactions. The Business Office Manager (BOM) was identified as having access to this account, and there were indications that resident payments intended for care and room and board were deposited into this account and potentially used for personal purposes. Despite these findings, the NHA was directed by the Director of Operations (DOO) and the facility owner not to report the incident to the State Agency or law enforcement, and no thorough investigation was initiated at that time. Several residents and their families reported concerns about missing payments, uncredited funds, and unexplained depletion of resident accounts. For example, one resident's family received bills despite having made payments, another resident's Social Security checks were unaccounted for, and a resident with severe cognitive impairment had checks written from their account with signatures that did not match their handwriting. In each of these cases, the concerns were either not investigated or only minimally reviewed, with no follow-up to determine the extent of the misappropriation or to identify all affected residents. Interviews with staff, residents, and family members confirmed that concerns about financial discrepancies were raised but not addressed. The NHA acknowledged being aware of the issues and sharing them with upper management, but was instructed not to alert authorities or conduct a full investigation. The lack of action allowed the misappropriation and exploitation to continue, and the facility did not ensure that residents were protected or that a thorough analysis of the situation was conducted, as required by facility policy.
Removal Plan
- Provide training to the NHA, DON, new BOM and members of the governing body about the intent of F610 and their responsibility to identify and investigate allegations of misappropriation of residents' funds.
- Conduct interviews of interviewable residents to identify concerns related to mishandling, misused and/or misappropriation of their funds. Report any identified concern to the state agency and law enforcement, and conduct an investigation. For residents unable to participate, interview resident representatives.
- Audit all residents' status of benefits (Medicaid and Managed Care) to identify concerns. Conduct an investigation if any concern is identified. Report any identified misappropriation of residents' funds and exploitation to the NHA, state agency and law enforcement.
- Complete assessment of all residents to identify any negative outcome. Notify the attending physician/NP of any negative findings.
- Initiate investigations while ensuring residents are protected from further misappropriation of property and exploitation.
- Provide training to the RDO, NHA, DON, and members of the governing body related to the intent of F610, facility policy related to investigation of allegations of misappropriation of resident property and exploitation, and staff responsibility to assure thorough investigation and implement measures to prevent further mishandling of finances and/or exploitation and to safeguard residents' finances.
- Provide training to department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) related to the intent of F610, facility policy related to investigation of allegations of misappropriation of resident property and exploitation, and staff responsibility to assure thorough investigation and implement measures to prevent further mishandling of finances and/or exploitation and to safeguard residents' finances.
- Provide staff with training about their responsibility to participate/cooperate with the administration when conducting an investigation. Staff who are not available will receive their education prior to starting their shift upon return to work.
Failure to Safeguard and Manage Resident Finances
Penalty
Summary
Facility administration failed to ensure effective and secure management of resident finances, resulting in a lack of oversight and accountability for resident accounts. The Business Office Manager (BOM) maintained a bank account in the facility's name, complete with a debit card and checkbook, which was unknown to the Nursing Home Administrator (NHA) and other management staff. This account was used for various cash withdrawals and purchases, with no effective system in place to determine the purpose or beneficiary of these transactions. Additionally, there was no tracking system for payments received from residents or their representatives, and the administration did not hold the BOM or third-party billing company accountable for the safe and accurate handling of resident funds. Multiple instances were identified where resident funds were mishandled. For example, a check from a resident was deposited into the undisclosed account after the resident had been discharged, and family members reported inaccurate statements, missing receipts, and unexplained balances. In one case, a resident's Social Security payments continued to be withdrawn for care costs after discharge, and the managed care organization (MCO) responsible for payment did not receive the funds, putting the resident at risk of losing benefits. The BOM was listed as the authorized user on the resident's account, preventing the MCO from making necessary changes without police involvement. These issues were compounded by poor communication with the third-party billing company and a lack of transparency with residents and their representatives. The administration did not follow regulations or facility policy regarding the reporting and investigation of suspected misappropriation or exploitation of resident finances. Despite being made aware of potential fraud and misappropriation, upper management advised against submitting a facility-initiated report to the State Agency or police, and a thorough investigation was not conducted. Policies and procedures for accounts payable and receivable were not provided when requested, and staff lacked the necessary education and tools to properly manage resident funds. These failures led to a finding of immediate jeopardy, as residents were placed at risk for misappropriation and exploitation of their funds.
Removal Plan
- The compliance consultant will provide the NHA, DON, new BOM and members of the governing body training about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death. To identify any negative outcome, the DON/SSD/Nurses will complete assessment of all residents. The attending physician/NP of the resident will be notified of any negative findings.
- The NHA and members of the governing body, NHA and Regional Director of Clinical Services will discuss the alleged deficiency and the corrective actions which are described in this plan of removal. The Administrator will notify the Medical Director of the alleged deficiency and immediate actions described in this plan of removal.
- To prevent the recurrence of the alleged deficiency, safeguard and track resident financials to include accounts payable and accounts receivables, an updated process will be implemented. The NHA/corporate regional representative will provide training to the new BOM about the new process. NHA to review and initial/sign off on all new accounts.
- Deposit process will be reviewed and updated to include two signers to accept checks and provide receipt with signatures. Both signers then log receipt of check on the Facility Check Receipt Log. Log will be reviewed weekly by facility NHA.
- Resident fund requests will be reviewed and updated: BOM makes withdrawal from resident's RFMS account and puts the money into the facility's RFMS Petty Cash account. BOM provides resident with requested money at the facility out of the RFMS Petty Cash box. RFMS Petty Cash box will be counted by the NHA and BOM weekly to ensure accuracy. Once RFMS Petty Cash box reaches a certain threshold (set by the NHA based on facility needs), a replenishment check will be requested. RFMS Petty Cash box will be counted. Receipts, G/L log and count will be sent to third-party billing office. Replenishment check will be issued to facility. Replenishment check will then be cashed at local bank. Funds will be counted at facility by two employees. Funds will then be placed back into the RFMS Petty Cash box.
- The policies and procedures related to administration of the facility will be reviewed by the NHA, DON, Medical Director and a representative of the governing body. The compliance consultant will provide the NHA, DON and members of the governing body training about administration of the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. It will be emphasized that the NHA and DON are accountable for all the programs and services in the facility to meet the needs of the residents who reside in the facility. The Administrator and DON are accountable for planning, coordinating and managing all services, including protection of residents from misappropriation of property and exploitation, meeting the reporting and thorough investigation requirements of any allegation related to misappropriation of resident property and exploitation, and are responsible for the overall direction, coordination and evaluation of all care and services provided to the residents in the facility.
- The NHA/DON will provide training to the department heads (Activities, SSD, BOM, Dietary Manager, Therapy Director, Environmental Services and Maintenance staff) about the intent of F835 and their responsibility to operate and manage the facility efficiently and effectively to ensure that the facility is administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The training will also include review of their responsibility to prevent abuse, including misappropriation of resident property and exploitation, identifying, investigating and protecting residents from allegations of abuse and exploitation that has the potential to cause serious injury, harm, impairment, or death.
Failure to Complete Required Employee Background Checks Prior to Employment
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a prior history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one of thirteen employee files reviewed, belonging to a registered nurse, did not contain a completed Background Information Disclosure (BID), Department of Justice (DOJ) response, or Government Findings report prior to the employee starting work. The facility's own policy requires that background checks be conducted and prohibits the employment of individuals with findings of abuse, neglect, exploitation, or misappropriation. During the survey, it was discovered that several personnel files were missing required documentation, and a facility-wide review was underway to identify which files were incomplete. However, as of the time of the survey, no missing documentation had been updated, and no list of affected employees was provided to the surveyor. The deficiency was identified through record review and staff interviews, confirming that the required background checks were not completed before the registered nurse began employment.
Failure to Complete Comprehensive Assessment After Catheter Removal
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for one resident who was re-admitted following a hospitalization and removal of an indwelling catheter. After the resident returned to the facility without the catheter, there was no documentation of comprehensive assessments or monitoring of the resident's ability to void or for potential complications, as required by the nursing process outlined in the Wisconsin Nurse Practice Act. Specifically, there was a lack of documentation from the day after re-admission through the following day, and the Director of Nursing acknowledged that the resident was not assessed or monitored appropriately after re-admission. Interviews with facility leadership revealed that there was no current policy on comprehensive assessments and nurse documentation at the time of the incident. The Director of Nursing and Regional Clinical staff reported that the facility had previously identified concerns with nursing assessments and documentation during a recent re-certification survey and were in the process of developing new policies, procedures, and documentation tools, but these were not yet implemented at the time of the deficiency.
Failure to Provide Required Infection Control Training to Housekeeping Staff
Penalty
Summary
The facility failed to ensure that required infection control training was completed for two housekeeping staff members. Both staff, identified as HSK E and HSK D, reported during interviews that they had not received any infection control training since their respective hire dates. This lack of training was confirmed through record review and staff interviews, indicating that the facility did not have a policy in place for infection control training for housekeeping staff. The Nursing Home Administrator acknowledged that there was no existing policy or documentation of infection control training for these staff members and confirmed that the required training had not been provided. The absence of infection control training for housekeeping staff has the potential to affect all 33 residents in the facility, as these staff perform duties that could impact infection prevention and control.
Failure to Timely Return Resident Trust Funds After Discharge or Death
Penalty
Summary
The facility failed to return funds from resident trust accounts to the residents or their representatives within 30 days after discharge or death, as required. Record review showed that three residents who were either discharged or had expired still had open accounts with remaining balances. Specifically, one resident with diabetes mellitus and multiple sclerosis was found deceased, yet their account remained open with a balance of $0.40. Another resident with hemiplegia following a cerebrovascular accident was discharged, but their account still showed a balance of $100.07. A third resident with heart failure was found unresponsive and deceased, and their account also remained open with a balance of $0.81. Interviews confirmed that the Nursing Home Administrator was aware of the open accounts and the unreturned funds, and acknowledged the lack of a policy for returning funds within the required timeframe. The Business Office Manager, who may have had further information, was unavailable due to being on FMLA. The failure to return funds in a timely manner was identified through both record review and staff interview, affecting three out of four residents reviewed for money due after discharge or death.
Failure to Assess, Document, and Obtain Consent for Wander Guard Use
Penalty
Summary
The facility failed to properly assess and document the need for a Wander Guard alarm for a resident with chronic obstructive pulmonary disease and severe cognitive impairment. The resident was admitted with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, but the most recent elopement risk evaluation documented the resident as not at risk for elopement. Despite this, the care plan identified the resident as an elopement risk and included the use of a Wander Guard device. The device was observed attached to the resident's left ankle, and staff confirmed its use. Interviews with facility staff revealed that there was no written consent or physician's order for the use of the Wander Guard, and no updated elopement risk assessment had been completed to justify its use. The Social Service Director had obtained only verbal consent from the resident's power of attorney after discussing the resident's behavior, but no written documentation of consent was present. The Interim Director of Nursing confirmed the absence of both a physician's order and written consent, as well as the lack of an updated risk assessment supporting the intervention.
Failure to Update Care Plan for Resident's Refusal of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan to include a resident's repeated refusals of pressure ulcer treatments and management. The care plan did not document the resident's refusals to have dressing changes performed, wound vac dressings assessed, or wet to dry dressings applied, despite multiple instances of such refusals being recorded in the nursing notes. The facility's policy required that the care plan describe services not provided due to the resident exercising their right to refuse treatment, but this was not reflected in the resident's care plan. The resident involved was cognitively intact, with a history of type two diabetes mellitus and an unstageable pressure ulcer of the sacral region. Nursing notes documented several occasions where the resident refused wound care, dressing changes, and interventions related to the wound vac, as well as non-compliance with turning and repositioning protocols. Despite these documented refusals and non-compliance, the care plan was not updated to reflect the resident's choices or the facility's response to these refusals.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Infection Control Failures During Wound Care and Catheter Management
Penalty
Summary
The facility failed to follow infection control practices during a dressing change for one resident with stage four pressure injuries to both heels. During the dressing change, an LPN placed the resident's wrapped heels on a clean barrier on the bed, then removed the dressings and placed the heels back on the same area of the barrier where the soiled dressings had been. The LPN also brought the treatment cart into the resident's room, contrary to facility expectations. The LPN later acknowledged not keeping clean and dirty areas separate on the barrier and admitted to making mistakes due to nervousness. The Interim Infection Preventionist confirmed that the nurse is expected to keep clean and dirty areas separate and not bring the wound cart into the resident's room. Additionally, the facility failed to maintain proper infection control for a resident with a suprapubic catheter. Observations showed the resident's catheter drainage bag was hanging on the side of the bed and touching the floor on two occasions. Both a CNA and an LPN confirmed that the drainage bag should not touch the floor, and the Interim Director of Nursing also acknowledged this expectation. Review of the facility's urinary catheter policy indicated that catheter tubing and drainage bags must be kept off the floor.
Failure to Complete Admission Skin Assessment for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive skin assessment upon admission for a female resident with multiple diagnoses, including diabetes mellitus type 2, severe obesity, and a stage 2 sacral pressure ulcer. The resident was admitted from the hospital with a documented stage 2 pressure injury, but the hospital discharge information did not include wound measurements. Upon admission, only a basic skin assessment was performed by an LPN, which noted bruising on the forearms but did not identify the sacral wound. A comprehensive skin assessment was not completed until two days after admission, at which point an RN documented the stage 2 sacral wound and its measurements. Due to the lack of an initial comprehensive assessment, there was no documentation to determine whether the pressure injury had worsened or improved since admission. The DON confirmed that a comprehensive skin assessment should have been completed upon admission, but this was not done, resulting in incomplete documentation and monitoring of the resident's pressure injury.
Failure to Supervise Resident During Meal
Penalty
Summary
The facility failed to provide the necessary supervision to prevent accidents for a resident, identified as R5, who required close supervision while eating due to aspiration precautions. On the morning of July 31, 2024, a surveyor observed R5 eating breakfast alone in his room without any staff present, despite his care plan and speech therapy recommendations indicating he needed supervision. R5's care plan, updated earlier in the month, specified that he should not be left alone with food and required assistance with eating. However, a Licensed Practical Nurse (LPN) left R5 unattended after administering medication, assuming a Certified Nursing Assistant (CNA) would arrive shortly to assist. The CNA, upon entering the room, expressed surprise that R5 had been given his plate without supervision, acknowledging that R5 was supposed to be monitored while eating. The CNA attributed the oversight to possible miscommunication or lack of awareness by the part-time LPN. Interviews with the LPN, Medical Director, and Speech Language Pathologist confirmed the requirement for supervision and the potential risk of choking if not adhered to. The incident highlighted a lapse in communication and adherence to care protocols, resulting in R5 being left unsupervised during a meal, contrary to his documented care needs.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to accurately assess and manage the pain of a resident, identified as R22, who was reviewed for pain management. The facility's policy requires pain assessments upon admission, quarterly reviews, significant changes in condition, and onset of new or worsening pain. However, R22's pain assessments were inconsistent and did not accurately reflect the resident's pain experience. For instance, R22's pain was documented as sharp and stabbing in the groin prior to hospitalization, but subsequent assessments failed to consistently identify the location and intensity of pain, which varied from 2/10 to 8/10. Additionally, the care plan was not individualized, as it only mentioned migraines and did not address other pain areas such as the back and legs. R22's physician orders included PRN Tylenol #3 and Extra Strength Tylenol, but no non-pharmacological interventions were ordered, and there were no scheduled pain medications. The Medication Administration Record (MAR) showed that R22 experienced moderate to severe pain on numerous days, yet the care plan did not reflect these findings. During interviews, R22 reported significant pain in his legs and back, which limited his mobility and ability to get out of bed. Despite these complaints, the facility did not reassess or adjust the pain management plan to address the resident's needs adequately. Interviews with staff, including a CNA and an LPN, revealed that R22's pain was not consistently managed, and there was a lack of communication regarding the resident's pain levels and management strategies. The LPN acknowledged that R22 had pain most days and attempted to get a scheduled pain medication order, but the physician did not approve it. The Director of Nursing (DON) admitted that the assessments did not indicate the location of R22's pain and recognized the need for changes. The failure to conduct comprehensive pain assessments and provide individualized care resulted in unmet pain management needs for R22.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a Kennedy terminal ulcer, which was in-house acquired and staged by hospice. The deficiency was identified when a surveyor observed a Certified Nursing Assistant (CNA) performing personal care for the resident without donning a gown, despite the presence of a yellow sign on the resident's door indicating that EBP was required. The CNA acknowledged the mistake, attributing it to a misunderstanding during the morning report, where she believed she was informed that EBP precautions were no longer necessary. The Director of Nursing (DON) confirmed that the EBP had been reinstated over the weekend after the resident's wound reopened, but this information was not communicated to the nursing staff on Monday. The facility's procedure for EBP involves the DON or Assistant Director of Nursing (ADON) determining the need for precautions, placing signage, and informing the floor nurse, who is then expected to relay the information to other nursing staff. The lack of proper communication led to the CNA not following the required EBP, resulting in the deficiency.
Failure to Establish Governing Body and Financial Mismanagement
Penalty
Summary
The facility failed to establish a governing body responsible for implementing policies regarding management and operation, leading to significant financial arrears that directly affect resident care. The facility owes substantial amounts to various service providers, including pharmaceutical services, staffing agencies, and electronic healthcare software providers. These overdue balances have resulted in some vendors ceasing their services, which could impact the quality of care provided to the 25 residents in the facility. The Nursing Home Administrator (NHA) indicated that financial concerns are not regularly discussed in meetings with the governing body, and the NHA has limited control over financial matters, which are managed by an external service center and the owner. Interviews with various representatives from service providers confirmed the outstanding balances and the cessation of services due to nonpayment. For instance, Pharm America, which provides medications for residents, has not received payment in 122 days and is considering switching to a cash-in-advance model. Other vendors, such as staffing agencies and suppliers of personal and medical supplies, have also stopped providing services due to unpaid invoices. The facility's financial issues are further compounded by overdue rent payments and bed taxes owed to the state. The owner admitted to hiring and subsequently terminating a financial management company, Future Care Consultants, which disrupted the facility's cash flow. The owner claimed that all vendors have been paid, but surveyors found evidence to the contrary. The NHA and the owner both acknowledged that financial concerns are not adequately addressed in Quality Assurance Program Improvement meetings, and the facility is currently transitioning to a new financial management service, Wipfli, to handle accounts payable and receivable.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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