Aria Of Brookfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookfield, Wisconsin.
- Location
- 18740 W Bluemound Rd, Brookfield, Wisconsin 53045
- CMS Provider Number
- 525424
- Inspections on file
- 39
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Aria Of Brookfield during CMS and state inspections, most recent first.
A resident with an activated POA had a grievance after the POA reported that a CNA had purposely unplugged the resident’s call light and voiced concerns about the resident’s care to the facility social worker. Facility policy required prompt investigation and verbal follow-up, including identification of the department head, steps taken, and final results. Administration later acknowledged knowing the POA had concerns but stated they were not aware of the complaint until surveyors informed them and that they did not follow up because they could not reach the POA. The POA reported receiving no updates or information about the investigation, and the facility failed to provide the required feedback and timely resolution of the grievance.
Surveyors observed that medications were not stored securely and expired medications were not handled according to facility policy. On a crash cart, three packs of Tiotropium Bromide Monohydrate inhalation powder labeled for a resident, including one used inhaler with a past use-by date, were found sitting on top of an unlocked, unsecured cart. The ADON acknowledged these inhalers should not have been left unsecured and should have been placed in the designated medication room for expired medications, contrary to the facility’s written medication storage policy requiring secure access and removal and destruction of expired drugs.
A resident with reduced mobility and muscle weakness, who was cognitively intact and care planned for assistance with toileting, activated a call light requesting help with a bedpan due to diarrhea and concern about soiling herself. Surveyors observed the call light on for 57 minutes before an ADON entered, asked what was needed, and provided assistance. During this period, multiple staff, including dietary and housekeeping personnel and a CNA responsible for the resident, entered or were aware of the situation but did not address the call light or provide the requested toileting assistance. This response time exceeded the facility’s stated expectation of responding to call lights within 15–20 minutes and did not follow the written call light procedure requiring timely response and completion of the resident’s request before turning off the call light.
Two residents with hemiplegia and significant ADL dependence were found without accessible call lights, despite care plan interventions and facility policy requiring call lights to be within reach. In one case, a resident with moderate cognitive impairment had the call button hanging below mattress level on the bedframe after staff set up a meal, and the resident did not know its location until a CNA later repositioned it. In another case, a resident who needed extensive assistance for mobility and toileting had the call light buried under linen on a chair, reported needing to be changed and frequently resorted to calling the main facility line for help, and remained without assistance for an extended period because staff were unaware of the need due to the inaccessible call light.
A cognitively intact resident with multiple chronic conditions reported that personal AirPods, believed to have been left in her room before a hospitalization, were missing. Facility staff used the resident’s iPhone link to track the device and found the AirPods in the possession of an LPN. The facility’s abuse prevention policy defined such conduct as misappropriation of resident property, and the incident was substantiated as staff misappropriation of a resident’s belongings.
The facility failed to ensure ordered wound treatments were consistently completed and documented for two residents with surgical and non-pressure wounds. One resident with a right femur fracture and surgical wounds to the right knee and shin had multiple days where daily wound care orders were not signed off on the TAR, with no documentation that treatments occurred. Another resident with a left BKA and a right foot surgical site had daily and M/W/F wound care orders, yet multiple treatment dates lacked documentation despite the resident reporting that dressings were changed and dressings being observed as dated. The wound treatment nurse stated she typically performed weekday wound care but admitted to poor documentation and was unsure who notified staff to cover treatments when she was absent, while LPNs reported they did not sign off wound care because wound nurses did it and they had not received text notifications instructing them to perform wound treatments. The DON stated that wound care was not considered completed if not documented and that documentation of treatments was expected per facility policy.
Two residents with pressure ulcers did not have their ordered wound treatments consistently documented as completed. One resident with a stage 3 toe ulcer and another with an unstageable sacral ulcer had daily and PRN wound care orders, but multiple dates on their TARs showed missing sign-offs with no evidence the treatments were done. The wound treatment nurse reported doing weekday treatments but admitted poor documentation, and stated that floor nurses were to perform treatments when she was absent and notified by text. Floor LPNs reported they did not sign off wound care because wound nurses handled it and that they had not received text notifications to complete wound treatments on the relevant days. The DON stated that wound care was considered not completed if not documented and that documentation of treatments was expected per facility policy.
The facility failed to follow physician orders, care plans, and internal policies for monitoring weights and nutritional intake for three residents with conditions such as diabetes, CHF, dysphagia, malnutrition, and visual impairment. Significant, unplanned weight losses were identified by the RD, but ordered weekly and monthly weights were not consistently documented, reweights requested by the RD were not recorded, and MDS assessments later showed no or unknown weight loss. Meal and supplement intakes were not routinely charted, despite care plan directives to monitor and record PO intake every meal, and one resident repeatedly refused ordered supplements without documented notification to the RD or physician. Observations showed residents with largely uneaten trays, difficulty seeing or accessing food, and poor appetite, while dietary staff did not record intakes and nursing leadership acknowledged that weight refusals and meal intakes were not consistently documented, contrary to facility policies on nutrition/hydration status and weight management.
A resident with end stage renal disease and an order for hemodialysis three times weekly did not receive a scheduled dialysis treatment when staff failed to ensure timely transport and access to a dialysis chair. The resident was rescheduled to an earlier time to accommodate an afternoon appointment, and a CNA began preparing the resident but left her on a bedpan and did not return. By the time day-shift staff and an LPN became involved, night shift reported they could not secure a dialysis chair, and the dialysis unit had no later availability, resulting in the resident missing the ordered dialysis session despite a care plan and facility policy requiring that needed dialysis services be provided.
Two residents with pressure injuries did not receive timely and appropriate assessment or treatment upon readmission. One resident was not assessed by an RN and developed multiple Stage 3 pressure injuries before being seen by a wound physician, with no preventive interventions documented. Another resident with a Stage 3 toe ulcer had no treatment ordered or completed for several days after readmission, and the care plan interventions were not promptly implemented. Staff interviews and observations revealed inconsistent communication and adherence to pressure injury protocols.
A resident with severe cognitive impairment and multiple medical conditions alleged being hit in the head by a CNA during care. Although the incident was reported to facility management and the resident’s POA soon after discovery, the required initial report to the state survey agency was not submitted within the mandated two-hour window, as the administrator delayed submission to gather more details.
Surveyors found that the facility's security alarm system only provided audible and visual alerts at the One South nursing station and near the front entrance, leaving other critical care areas without notification when the alarm was triggered. Staff in other units, including a CNA and an RN, confirmed they could not hear the alarm, and facility leadership acknowledged the lack of facility-wide alert capability.
Nurses did not consistently sign narcotic count sheets or verbalize medication and resident names during shift change counts for multiple medication carts. Observations and interviews confirmed that the required process for controlled substance accountability was not followed, resulting in numerous missing signatures and incomplete documentation.
A resident with severe cognitive impairment was physically abused by a family member during a visit, when the family member threw a remote and struck the resident on the forehead. Despite having an abuse prevention policy, the facility failed to prevent this incident, as confirmed by staff interviews and documentation.
Medications and biologicals were left unsecured on a nursing unit, with 15 medication cards left openly on a desk and two unattended medication carts found unlocked and accessible. An LPN confirmed the medications should have been secured after pharmacy delivery, and the Director of Quality Assurance verified that facility policy requires all medications and carts to be locked when unattended.
The facility experienced significant staffing shortages during a weekend, leading to inadequate care for residents. Interviews revealed long wait times for assistance, with one resident left wet for 90 minutes and another experiencing delays in call light responses. Management acknowledged the issue, citing a staff party as a contributing factor, but did not use agency staff to fill gaps.
A resident was prescribed multiple psychotropic medications without obtaining the necessary written consent from their activated Health Care Power of Attorney (HCPOA). Despite the facility's policy requiring signed consent, no documentation was found in the resident's electronic health record, and the HCPOA confirmed they had not signed any consents. The facility's administration was informed of the deficiency, but no further information was provided to address the issue.
The facility failed to provide prior written notice to four residents regarding room changes, as required by their policy. A resident was moved without prior notice or a choice of rooms due to safety concerns, but there was no documentation of the incidents. Another resident was transferred without a choice or documented reason, and two residents with impaired decision-making abilities were moved without notifying their HCPOAs.
A resident reported that a CNA refused to assist her with using a bedpan, instructing her to use her diaper instead. The resident informed another CNA, but the allegation was not reported to the NHA or State agency as required. The facility's policy mandates immediate reporting of such incidents, but the NHA was unaware until informed by a surveyor.
A resident reported neglect when a CNA refused to assist with a bedpan, instructing the resident to use a diaper instead. The incident was reported to another CNA, who failed to escalate the allegation, allowing the accused CNA to continue working. This violated the facility's policy requiring immediate removal of staff accused of neglect.
A resident with moderate depression did not have a comprehensive person-centered care plan addressing mood/psychosocial needs, despite being prescribed medications and treated by a psychologist. The facility's policy requires such plans, but the resident's care plan lacked specific interventions. The issue was confirmed by staff and noted during a surveyor's review.
Two residents in an LTC facility did not receive necessary assistance with activities of daily living. One resident, with multiple health issues, was left without incontinence care for five hours, resulting in a urine-stained sheet. Another resident, with diabetes and renal disease, received only four showers since admission, despite her preference for regular showers. The facility failed to adhere to care plans and documentations, leading to deficiencies in care.
The facility failed to provide adequate supervision and fall prevention for three residents, leading to unaddressed fall risks and unsupervised meals. A resident at high risk for falls did not have proper interventions documented, another was left unsupervised during meals despite choking risks, and a third resident's fall was not thoroughly investigated, lacking witness statements.
A resident with multiple behavioral health diagnoses did not receive necessary services to address significant behavioral changes, including substance abuse issues. The facility failed to update the care plan with new self-harm behaviors and did not conduct a root cause analysis or develop non-pharmacological interventions. Communication lapses between staff and healthcare providers further contributed to the deficiency.
A resident was discharged with discontinued medications, and their scheduled medications were administered late on multiple occasions. The facility did not follow its policies for medication disposal and administration timing, leading to deficiencies in pharmaceutical services.
A resident did not receive their preferred breakfast items and essential dietary supplement, Nepro, as listed on their meal ticket. The resident, who has multiple health conditions including End Stage Renal Disease, expressed that they frequently do not receive meal preferences. The Dietary Manager and Registered Dietitian confirmed the oversight, attributing it to CNAs and Dietary Aides not reading meal tickets properly. The issue was acknowledged by facility leaders.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and PPE usage. Staff did not perform hand hygiene during incontinence care and wound treatment, and the Nursing Home Administrator entered a COVID-19 isolation room without appropriate PPE. These actions violated the facility's infection control policies.
The facility failed to ensure resident safety, resulting in injuries and uninvestigated falls. A resident was injured during an improper transfer, while others experienced multiple falls without thorough investigation or timely care plan updates. Additionally, a Wanderguard bracelet was improperly placed, potentially compromising its function.
The facility failed to maintain a clean and safe environment, with dining areas and hallways observed to be unclean and unsanitary. Dining areas had dried food debris and stains, and residents were eating in these conditions. Staff interviews revealed confusion over cleaning responsibilities, and maintenance issues such as water-stained ceiling tiles and protruding metal pieces were noted. The Nursing Home Administrator and Director of Nursing were informed, but no corrective actions were detailed.
Two residents in a facility did not consistently receive scheduled showers or bed baths, as required by the facility's policy. One resident, with multiple health conditions, did not receive assistance for bathing on several occasions, and there was no documentation of refusals or interventions. Another resident, with serious health issues, also missed a scheduled shower, and the CNA Kardex lacked specific scheduling details. The facility failed to adhere to its bathing policy, resulting in a deficiency.
A resident with chronic respiratory failure was found with an empty oxygen humidification bottle, contrary to facility policy requiring it to be filled with sterile distilled water. Despite the resident's care plan and physician orders for oxygen therapy, staff failed to maintain the humidifier bottle, which was acknowledged by an LPN and the ADON. The deficiency was reported to the facility's administration, but no explanation was provided.
The facility did not maintain legible nurse staffing documents for 39 days, affecting all 101 residents. The Nurse Staff Posting form was illegible due to black specks, extra lines, and slanted text. The issue was not addressed until a surveyor intervened, and the facility's policy did not cover the requirement for legible documentation.
A facility failed to prevent and manage pressure injuries for three residents, leading to the development and deterioration of wounds. A resident developed a Stage 4 pressure injury due to delayed assessment and inadequate care planning, resulting in hospitalization. Another resident's care plan was not updated promptly, delaying treatment for pressure injuries. A third resident's pressure ulcers were not staged correctly, and skin monitoring interventions were not followed.
A resident with a history of exit-seeking behaviors and cognitive impairment eloped from the facility due to inadequate supervision and interventions. Despite being assessed as a high elopement risk, the resident's Wanderguard was removed without additional supervision. The resident was last seen smoking on facility grounds and was later found 17 miles away. The facility failed to document and monitor the resident's behaviors and medication refusals, contributing to the deficiency.
Two residents in an LTC facility did not receive appropriate care according to their care plans. One resident with a surgical incision did not have timely assessments or care plans, leading to hospitalizations for infections. Another resident's lab results indicating significant abnormalities were not reported promptly, resulting in a hospital transfer. Facility policies on wound management and change of condition were not followed, leading to inadequate monitoring and documentation.
Two residents with diabetes and other health conditions were found to have long, unkempt toenails, indicating a deficiency in foot care. One resident's medical record lacked evidence of podiatrist visits, and the facility did not have a diabetic foot care policy. Another resident's care plan for foot care was inconsistently implemented, with missed daily checks and no recent podiatry consult.
A resident with severe depression and cognitive impairment did not receive adequate social services to achieve their highest quality of life. The facility failed to develop a care plan addressing the resident's mental health needs and did not follow up on a vague discharge planning evaluation. Despite the resident's expressed desire to leave and an elopement incident, no referrals were made, as the guardian wanted the resident to remain at the facility.
A resident experienced significant medication errors due to the facility's failure to timely administer prescribed medications and communicate with the prescribing nurse practitioner. The resident, with a history of dementia and depression, did not receive Zoloft as recommended and refused multiple doses of Seroquel and Zoloft without proper documentation or notification to the prescriber. Additionally, the facility did not address new diabetes management instructions from a hospital visit, failing to implement necessary blood sugar testing and insulin administration.
The facility failed to coordinate hospice services for two residents, leading to inconsistent care and communication issues. One resident did not have a designated staff member to coordinate hospice care, resulting in confusion about wound care responsibilities. Another resident's hospice visit notes were not updated, and hospice staff were unaware of pressure injuries. These deficiencies led to inadequate wound care management and documentation, impacting the quality of care provided.
A resident with multiple health conditions experienced significant weight changes that were not reported to the physician as required by facility policy. The facility failed to obtain daily weights as ordered, leading to a deficiency noted by surveyors. Staff interviews revealed inconsistencies in the process of monitoring and reporting weights.
A resident with a history of aggression was not adequately supervised, leading to verbal and physical altercations with other residents. Despite known behavioral issues, staff failed to consistently monitor and document incidents, resulting in a deficiency in providing a safe environment.
The facility failed to maintain a clean and safe environment, with surveyors observing unsanitary conditions such as brown material resembling bowel movement in bathrooms, food particles, and debris in resident rooms. Common areas had missing ceiling tiles, food debris, and stained carpets, while the main lobby had a sewage smell. Housekeeping staff were unable to address these issues effectively, leading to repeated observations of the same deficiencies.
The facility failed to provide proper wound care and treatment administration for several residents. One resident's wound vac treatment was not correctly documented, leading to conflicting administration times and incorrect pressure settings. Another resident had multiple treatments ordered for the same MASD area without clarification, and a new wound was not entered into the TAR. A third resident's toe injury was not assessed or reported to a physician, and a bladder scan was not completed for another resident as ordered.
A resident with osteomyelitis, anxiety, and depression, who was cognitively intact, requested to self-administer medication due to perceived errors. The facility failed to complete the necessary assessment, leaving sections and approvals incomplete. The resident was not consulted by physicians, and a statement from the new physician cited safety concerns without direct communication with the resident.
A resident with severe cognitive impairment was not provided personal privacy during toileting when a CNA was unable to close the bathroom door and did not close the privacy curtain, allowing the roommate to see the resident. The facility's policy on privacy was not followed, resulting in a breach of the resident's privacy.
Two residents with intact cognitive function filed grievances that were not resolved promptly by the facility. The Nursing Home Administrator failed to document essential information and did not retain original grievance documents, leading to unresolved issues and lack of communication with the residents.
A resident with a new diabetes diagnosis was discharged without receiving necessary education on blood sugar monitoring and medication administration. The facility's records lacked documentation of this education, and staff interviews revealed uncertainty about whether it was provided. This deficiency in discharge planning was noted by surveyors.
A resident with osteomyelitis and anxiety was not consistently receiving showers twice a week as per the facility's policy. Despite being cognitively intact and not refusing care, the resident reported not receiving scheduled showers, and facility records confirmed inconsistencies in documentation. The DON and QA Director were unaware of any complaints or refusals, indicating a deficiency in policy adherence.
Two residents at the facility did not receive appropriate pressure ulcer care and prevention. One resident, with severe cognitive impairment, was observed without a pressure-relieving cushion in their wheelchair, contrary to their care plan. Another resident with a Stage 3 pressure ulcer had incorrect wound care orders transcribed and implemented late, and was observed without pressure-relieving boots. These deficiencies were noted over several days, indicating a failure to adhere to care plans and physician orders.
Two residents in a facility were not provided adequate supervision and safety measures, leading to deficiencies. One resident, at high risk for falls, was transferred without a gait belt, contrary to facility policy. Another resident's bed was often left in a high position, and the call light was out of reach, against care plan directives. These issues were observed over several days and confirmed by staff.
Failure to Provide Required Follow-Up on Grievance Regarding Call Light Disconnection
Penalty
Summary
The facility failed to honor a resident’s right to voice grievances without reprisal by not following its own grievance policy for a resident whose POA reported concerns. The facility’s policy required that all grievances, whether verbal or written, receive immediate priority, be investigated with efforts toward resolution within seven days, and that the resident be provided with verbal follow-up including the name of the department head conducting the investigation, the steps taken, and the final results. The resident, who had an activated POA, was admitted on a specified date, and the POA reported to surveyors that in approximately October a CNA had purposely unplugged the resident’s call light and that she was concerned about the resident’s care. The POA stated she had informed the facility social worker at the time of the event. During a state survey, the POA told surveyors she had not received any information from the facility and was unaware of what was happening with the resident’s care. The facility only submitted a report to the State Agency after surveyors notified them of the complaint on a later date, at which point the facility conducted an investigation and submitted findings to the State Agency. The Nursing Home Administrator acknowledged awareness that the POA had concerns but stated that administration was not aware of the concern until surveyors brought it to their attention and that the facility had not followed up with the POA because they were unable to reach her. The POA reported that she had received no updates at any point during the investigation. As a result, the facility did not provide the required feedback or timely resolution of the grievance as outlined in its grievance policy.
Unsecured and Improperly Managed Inhaler Medications on Crash Cart
Penalty
Summary
Surveyors found that the facility failed to ensure medications were stored securely and that expired medications were removed from active use and discarded appropriately. During a review of crash carts with the Assistant Director of Nursing (ADON), three packs of Tiotropium Bromide Monohydrate inhalation powder labeled with Resident 16’s name, with an expiration date of 01/2027, were observed sitting on top of an unlocked, unsecured crash cart on 2 South. One of the inhalers had been used and had a use-by expiration date of 08/21/25. The ADON acknowledged at the time of observation that these medications should not have been left unsecured on the crash cart and stated that there was a designated medication room for expired medications where such inhalers should have been placed for pharmacy retrieval and disposal. Review of the facility’s January 2018 policy titled “Medication Storage in the Facility” showed that medications and biologicals are to be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that all expired medications must be removed from the active supply and destroyed in the facility in the usual manner. The observed unsecured storage of labeled inhalers on the crash cart and failure to follow the process for handling expired medications were inconsistent with this written policy.
Failure to Respond Timely to Resident Call Light for Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to respond in a timely manner to a cognitively intact resident’s call light request for assistance with toileting. The resident had diagnoses including reduced mobility and muscle weakness and a care plan that required her call light to be kept within reach and that she receive assistance of one staff member with toileting. On the day of the incident, the resident reported that she had pressed her call light around 11:00 AM because she needed help with a bedpan, believed she might have soiled herself due to diarrhea, and stated that her bottom was sore. Surveyors first observed the call light illuminated above her door at 12:51 PM, with the call button near her hand, and the resident reported that she sometimes waited up to an hour for her call light to be answered and that this occurred almost daily. Between 12:51 PM and 1:48 PM, multiple staff entered the room but did not address the call light or the resident’s request. A dietary aide entered to remove the lunch tray and a housekeeping supervisor entered to remove garbage; neither asked the resident why her call light was on. A housekeeper later entered and, upon leaving, spoke with a CNA across the hall, who stated she was the resident’s aide and that she had to care for residents going to dialysis before assisting this resident. The call light remained on until 1:48 PM, when the ADON entered the room, asked what the resident needed, turned off the call light, and assisted her with the bedpan, 57 minutes after the call light was first observed on by surveyors. The ADON and DON both stated that staff were expected to respond to call lights in a timely manner, with the DON specifying an expectation of within 15 to 20 minutes, and the facility’s call light policy required timely response and that the call light remain on until the request was completed.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failure to ensure resident call lights were accessible as required by facility policy and resident care plans. One resident with hemiplegia and hemiparesis following a stroke, and a BIMS score indicating moderate cognitive impairment, had a care plan intervention directing staff to keep the call light within reach and encourage its use. During observations, this resident was seen in bed after staff had set up breakfast, with the call button hanging over the upper left corner of the bedframe below mattress level and out of reach. Over an hour later, the call button remained in the same inaccessible position, and the resident reported not knowing where it was, stating that staff usually clipped it to the blanket but it might have moved when they sat him up for breakfast. A CNA who was not assigned to the resident confirmed the call button was out of reach and moved it to the tray table. Another resident with hemiplegia and hemiparesis following a stroke required total assistance with most ADLs, extensive assistance of two persons for bed mobility and transfers, and physical assistance for toileting. During observation, this resident was in bed talking on a cell phone while the call light was buried under linen on a chair, out of reach. The resident stated needing to be changed but having no way to call for help, and reported that this situation occurred frequently, leading the resident to call the main facility line and ask for the nursing supervisor for assistance. The resident reported having made such a call about 15 minutes earlier, and approximately 45 minutes later still had not received assistance. When informed, a CNA entered the room and confirmed the call light was not within reach and was located on a chair far from the resident. The DON and Administrator both stated their expectation that call lights be within residents’ reach at all times, and the facility’s written procedure required staff, when leaving a room, to ensure the call light is placed within the resident’s reach and to monitor call light location during rounds.
Failure to Protect Resident Property From Misappropriation by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s personal property from misappropriation. A cognitively intact resident, with a BIMS score of 13 out of 15 and medical diagnoses including multiple sclerosis, spastic hemiplegia affecting the left dominant side, and type 2 diabetes mellitus, reported that her AirPods were missing. The resident believed she had left the AirPods in her room before a hospitalization. The facility’s self-reported incident indicated that staff used the resident’s iPhone link to track the missing AirPods. The AirPods were subsequently located in the possession of an LPN who was employed at the facility at that time. The facility’s abuse prevention policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident’s belongings or money without the resident’s consent, including obtaining property by intentional deception or using personal identifying information. During an interview, the resident confirmed that her AirPods had gone missing and that the facility found the nurse who took them and returned the AirPods. In a later interview, the Administrator was informed that, because the facility substantiated the allegation of misappropriation by its staff, the facility was responsible for the employee’s actions.
Failure to Complete and Document Ordered Wound Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered wound treatments were both completed and documented for residents with non-pressure surgical wounds. One resident with a displaced comminuted fracture of the right femur had orders for daily and PRN wound care to the distal end of the right hip incision (right knee) and right shin, including cleansing with normal saline, application of collagen sheet and xeroform, and coverage with ABD and Kerlix. The resident’s care plan identified a risk for impaired skin integrity with non-pressure wounds to the right shin and right knee and included an intervention to provide skin care per facility guideline and PRN. Review of the Treatment Administration Records (TARs) for this resident showed multiple dates on which the ordered wound treatments were not signed off as completed and remained without documentation, and there was no additional documentation provided to show that the treatments were done on those dates. Another resident with a history of left below-knee amputation and peripheral vascular disease had care plan interventions that included encouraging compliance with the treatment regimen. This resident had orders for daily and PRN wound care to the left BKA surgical wound, involving cleansing with normal saline and packing with Dakin’s-soaked gauze, and separate orders for wound care to a right foot surgical site on a Monday/Wednesday/Friday and PRN schedule, including washing with soap and water and applying betadine and dry gauze. Review of this resident’s TARs for December and January revealed multiple dates on which the treatments for both the left BKA and the right foot surgical site were not signed off as completed and remained without documentation. During observation and interview, the resident reported that wound care was being done every day to the left leg and every other day to the right foot, and both dressings were dated, indicating treatments had been completed earlier in the shift, despite the lack of corresponding documentation on the TARs. Interviews with staff revealed inconsistent practices and gaps in responsibility for wound treatment and documentation. The wound treatment nurse reported that she performed the facility’s wound treatments Monday through Friday, with other wound care nurses covering weekends, and that if she was sick or not working, another nurse or the floor nurses were expected to complete the treatments. She stated that when she was sick, the facility sent text messages to floor nurses to complete treatments, but she was unsure who notified nurses on a specific date when she was absent and acknowledged she was “bad with documenting” treatments on the TAR. Floor LPNs reported that they did not sign off wound treatments on the TAR because wound nurses completed them and that they relied on text notifications to know when they needed to perform wound care; they stated they had not received such texts during the relevant period, including on a date when the wound nurse was out sick. The DON stated that, in general, wound care was not considered completed if it was not documented and that wound care was expected to be documented as completed, with floor nurses responsible for treatments when the wound care nurse was unavailable. The facility’s documentation policy required timely documentation of actual events, including treatments, which was not followed in these instances.
Failure to Complete and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered pressure injury treatments were both completed and documented for two residents with pressure ulcers. For one resident with diabetes, peripheral vascular disease, and intact cognition, the EMR showed an order for daily and PRN wound care to a stage 3 pressure ulcer on the left second toe, including cleansing with normal saline and application of silver sulfadiazine 1% and calcium alginate. The resident’s care plan identified risk for impaired skin integrity and a stage 3 pressure ulcer to the left second toe, with an intervention to provide skin care per facility guidelines. Review of the Treatment Administration Records (TARs) for December and January revealed multiple dates on which the ordered toe wound treatment was not signed off as completed and remained without documentation, and there was no documentation provided that the treatments were completed on those dates. A second resident, admitted with osteomyelitis and diabetes and assessed as severely cognitively impaired, had been admitted with a stage 2 pressure ulcer that received treatment. The EMR contained an order for daily and PRN wound care to a sacral pressure injury, specifying cleansing with normal saline and application of silver sulfadiazine 1% and calcium alginate. The care plan documented an unstageable sacral wound and included an intervention to administer treatments as ordered and monitor for effectiveness. Review of this resident’s TARs for December and January showed that the sacral wound treatment was not signed off as completed on several dates and remained without documentation, with no evidence provided that the treatments were completed on those days. Interviews with staff further clarified the actions and inactions leading to the deficiency. The wound treatment nurse reported she was responsible for wound treatments Monday through Friday and that other wound care nurses completed treatments on weekends, with floor nurses expected to complete treatments if the wound nurse was absent and notified by text. She stated she had been sick on one of the dates in question but otherwise did all wound treatments, and acknowledged she was “bad at documenting” treatments on the TAR. Floor LPNs reported they did not sign off wound treatments because wound nurses completed them and that they had not received text notifications instructing them to perform wound care on the dates in question, despite having worked those days. The DON stated that, in general, wound care was considered not completed if it was not documented and that wound care was expected to be documented as completed, consistent with facility policies on wound management and documentation expectations.
Failure to Monitor Weights and Nutritional Intake for Residents with Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document weights and nutritional intake, and to report significant changes in eating and supplement consumption for multiple residents with known nutritional risks. For one resident with diabetes, dysphagia, and moderate protein-calorie malnutrition, orders were in place for weekly then monthly weights, and the care plan directed that the resident be weighed per facility protocol. The weight record showed an 11.7% loss between late September and mid-October, followed by no documented weights until early January, when an additional 10.5 lb loss was recorded. A nutrition note in mid-October identified a significant, unplanned, and unfavorable weight loss and requested a reweight to confirm accuracy and assess for ongoing change, but there was no documentation of intervening weights or refusals. The quarterly MDS later documented no or unknown weight loss despite these changes, and there was no evidence in the record that the resident refused to be weighed. Another resident with diabetes, morbid obesity, CHF, and glaucoma had two active orders for weekly weights, including daily weights before breakfast and weekly weights for CHF with notification parameters for rapid weight gain. The care plan required monitoring and recording of PO intake and weighing as ordered by the physician. The weight summary showed an 8.7% loss over a short period in October, with no further weights documented afterward. A nutrition note identified a significant, unplanned, and unfavorable weight loss and recommended continued monitoring of intakes and weights per facility protocol. However, there were no documented current weights on the subsequent annual MDS, which recorded no or unknown weight loss, and review of the EMR revealed no documentation of weight refusals or recorded meal intakes. Observations showed the resident repeatedly with largely uneaten breakfast trays, reporting poor appetite, visual difficulty seeing the tray, and variable eating, while staff interviews acknowledged that the ordered weights had not been done and that intakes were not routinely documented. A third resident with protein-calorie malnutrition and dysphagia experienced a documented 6.0% weight loss between late September and mid-October, after which no further weights were recorded despite an order for weekly weights followed by monthly weights. A nutrition note identified this as a significant, unplanned, and unfavorable weight loss, recommended increasing a high-calorie supplement to three times daily, and directed monitoring of PO intake with a goal of 50% of meals and monitoring of weights per facility protocol. The care plan was revised to reflect risk for malnutrition, with interventions to weigh per facility protocol and to monitor and record intake every meal. Medication records showed that the resident did not consume the ordered Proheal supplement on a large number of occasions in December and January, yet there was no documentation that the RD or physician were notified of these refusals, no recorded meal intakes, and no documentation of weight refusals. Observations showed the resident, who was legally blind, unable to see or access food on the tray and not eating, while dietary aides reported they did not record intakes and did not consistently notify nursing when residents ate little or nothing. Nursing leadership and the RD acknowledged reliance on facility protocol for weights, lack of documentation of refusals, and uncertainty about intake documentation, despite facility policies requiring routine monitoring of nutritional status, weighing per protocol, and evaluation of significant weight variances. Facility policies on Nutrition/Hydration Status Maintenance and Weight Management required that residents be provided assistance with eating and drinking as needed, be routinely monitored for changes in nutritional status using data such as weights and intake records, and be weighed monthly or more often as clinically indicated. The policies also required that significant weight variances prompt evaluation, documentation of potential causes, and interventions, and that reweights be obtained for significant changes unless otherwise ordered. In practice, for the three residents reviewed, ordered and policy-required weights were not consistently obtained or documented, significant weight losses identified by the RD were not followed by documented reweights or ongoing monitoring, and meal and supplement intake records were absent despite care plan directives. Staff interviews confirmed that intakes were not routinely documented, refusals of weights were not recorded, and concerns about poor intake were often communicated informally, if at all, rather than through the EMR or formal notification to the RD or physician.
Failure to Ensure Transport and Access to Scheduled Dialysis Treatment
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis was transported to receive the ordered treatment, resulting in a missed dialysis session. The resident had end stage renal disease and a physician’s order for hemodialysis on Monday, Wednesday, and Friday during the day shift, with instructions that if dialysis was missed for any reason, a BMP lab was to be drawn the following day and reported to the physician. The resident’s care plan identified a need for dialysis three times a week and included an intervention to encourage attendance at scheduled dialysis appointments. The resident was cognitively intact, with a BIMS score of 15, and routinely received dialysis. On the day of the incident, the resident was scheduled for an earlier-than-usual 5:00 AM dialysis time to accommodate an afternoon appointment, and the on-site dialysis center was reported to be full, requiring residents to be switched around. A night-shift CNA began preparing the resident for dialysis and placed her on a bedpan but did not return, leaving the resident unattended until day-shift staff arrived. By the time day-shift staff and the LPN became involved, night shift reported they were unable to find a dialysis chair for the resident, and the dialysis unit had no available chair later in the day, resulting in the resident missing the scheduled dialysis treatment. The DON reported that a night-shift CNA had called about not being able to locate a dialysis chair and was instructed to search the facility, dialysis area, and room and get the resident to dialysis, but the resident ultimately did not receive the ordered dialysis session.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice, resulting in deficiencies for two residents. One resident with a history of pressure injuries and multiple comorbidities, including diabetes, morbid obesity, and vascular disease, was readmitted to the facility without a comprehensive skin assessment by an RN. Upon readmission, redness was noted by an LPN on the coccyx and buttocks, but no measurements or detailed characteristics were documented, and no RN assessment was completed. It was not until a scheduled wound physician visit several days later that three Stage 3 pressure injuries were identified and treatment was initiated. Prior to this, there was no documentation of preventive treatments or interventions, such as barrier cream, and no evidence that staff were consistently implementing care plan interventions like repositioning with a draw sheet or using positioning devices. Interviews revealed that staff were unclear about the resident's repositioning needs, and the resident reported never being offered pillows or assistance for offloading pressure. Another resident was readmitted with a known Stage 3 pressure injury to the right fifth toe. Although the wound was documented upon readmission, there were no treatment orders for five days, and no wound care was completed until a week later. The treatment administration record (TAR) did not reflect a scheduled daily treatment order, and the first documented treatment occurred only after the wound physician assessed and debrided the wound. The care plan included pressure-relieving devices and protocols for injury treatment, but these were not implemented in a timely manner. Interviews with the wound nurse confirmed that the treatment order should have been placed and initiated upon readmission, but this did not occur. Observations and interviews throughout the survey period highlighted lapses in communication, documentation, and adherence to facility policy regarding skin assessments and pressure injury prevention. Staff were not consistently aware of or implementing individualized care plan interventions, and there was a lack of timely and comprehensive assessment and treatment for residents at risk for or with existing pressure injuries. These failures resulted in delayed identification and management of pressure injuries, contrary to professional standards and facility policy.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within the required two-hour timeframe for one resident. According to facility policy, any allegation of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be reported immediately, defined as no later than two hours after forming the suspicion if serious bodily injury is involved. In this case, a resident with severe cognitive impairment and a history of chronic kidney disease and major depressive disorder reported being hit in the head by a CNA during care. The allegation was discovered by facility management after the resident’s POA reported observing the incident on camera and after the resident made a direct accusation to staff. Facility documentation shows that the incident was discovered at approximately 9:08 AM, but the initial report to the state survey agency was not submitted until 1:27 PM, exceeding the two-hour reporting requirement. The administrator confirmed that the report was delayed because she waited to obtain more details before submitting it. The deficiency centers on the failure to promptly report the abuse allegation as required by both facility policy and regulatory standards.
Failure to Ensure Facility-Wide Security Alarm Notification
Penalty
Summary
Surveyors observed that the facility failed to ensure its security alarm system was capable of alerting staff throughout the entire building when triggered. On the morning of the survey, two surveyors entered the facility through an unlocked front entrance, which activated a loud screeching alarm near the entrance and a beeping sound with visual indicators at the One South nursing station. However, as the surveyors moved further into the building, the alarm became less audible and was not heard at the One East/West nursing station or on the second floor. Staff present in these areas, including a CNA and an RN, confirmed they could not hear the alarm when it was triggered. Interviews with facility leadership and staff, including the Maintenance Director, Facility Administrator, DON, Director of QA, and CIO, confirmed that the alarm system only provided audible and visual notifications at the One South nursing station and did not communicate alerts to other critical care areas. The system was not monitored by a security company, and information about alarm activations was not relayed to other units. The Director of QA acknowledged the need for an alarm system that could notify all critical care areas, particularly beyond the One South nursing station.
Failure to Document and Accurately Perform Narcotic Shift Counts
Penalty
Summary
The facility failed to ensure that at the completion of the narcotic count, both nurses who participated in the counting documented the accurate count at the change of each shift for three of four medication carts reviewed. Observations revealed that during the narcotic count process, nurses did not consistently sign the accountability pages in the narcotic count binders at shift changes. Specifically, multiple count sheets for the medication carts on 1 South, 1 East, and 2 South B were missing numerous required signatures, with some days showing no signatures at all. The facility policy required two licensed nurses to conduct and document a physical inventory of all controlled substances at each shift change, but this was not followed as evidenced by the missing signatures. Additionally, during the observed narcotic count, nurses did not verbalize the names of the drugs or the residents for whom the medications were prescribed, contrary to facility policy. Instead, only the number of medications on each card was announced. Interviews with nursing staff and facility leadership confirmed that the expected process was not being followed, as both the names of the medications and residents should have been verbalized and the count sheets signed by both nurses at each shift change.
Failure to Protect Resident from Abuse by Family Member
Penalty
Summary
A resident with vascular dementia and severe cognitive impairment, as indicated by a BIMS score of 3 out of 15, experienced an incident of physical abuse during a family visit. The resident was involved in an altercation with a family member, during which the family member became frustrated, threw a television remote at the resident, and then struck the resident on the forehead. The incident was observed and reported by facility staff, and the resident confirmed that the family member had hit him. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, or mistreatment and outlines the facility's responsibility to establish a secure environment. Despite this policy, the facility failed to protect the resident from abuse by a family member during a visit. The event was documented in the resident's progress notes, and the incident was confirmed through interviews with staff and review of the resident's medical record.
Unsecured Medications and Unlocked Medication Carts
Penalty
Summary
Medications and biologicals were found unsecured on the second floor south nursing unit. At 5:15 AM, 15 medication cards were observed sitting openly on the nursing station desk with no staff present, while a resident was ambulating nearby. Additionally, two medication carts parked near the station were found unlocked, with drawers containing resident medications accessible and unattended. An LPN confirmed that the medications delivered by the pharmacy at approximately 4:00 AM should have been secured and not left on the desk. The LPN also acknowledged that the medication carts should have been locked when unattended. The Director of Quality Assurance further confirmed that facility policy requires medication carts to be locked when not attended and that medications should not be left unsecured on the desk.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, particularly during the weekend of January 25-26, 2025. Interviews with staff, residents, and family members revealed significant concerns about staffing levels, which led to long wait times for residents needing assistance. The facility's staffing plan indicated a minimum number of staff required, but the actual staffing levels during the weekend in question were below these requirements. This deficiency affected all 43 residents on the first floor, as the facility failed to provide adequate nursing-related services to ensure their safety and well-being. Specific incidents highlighted the impact of the staffing shortage. A resident, identified as R23, reported experiencing long wait times while incontinent, and staff confirmed that the facility was short-staffed during that weekend. Another resident, R30, was left wet for at least 90 minutes, and family members expressed concerns about the lack of attention and supervision provided to R30, who was unsteady and confused. The facility's inability to maintain sufficient staffing levels resulted in delayed responses to call lights and inadequate care for residents, as confirmed by interviews with staff and family members. The facility's management acknowledged the staffing issues, citing a birthday party attended by many off-duty CNAs as a contributing factor to the shortage. Despite efforts to recruit staff for vacant shifts, such as offering bonuses and meals, the facility struggled to fill the gaps. The facility did not use agency staff to address the shortage, and ongoing efforts to hire new staff were noted. However, the deficiency in staffing during the specified weekend remained unaddressed, impacting the quality of care provided to residents.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain a written consent explaining the risks and benefits of psychotropic medications for a resident, identified as R26, who was prescribed multiple psychotropic drugs including Zoloft, Lexapro, Remeron, and Prozac. Despite the facility's policy requiring signed consent prior to administering such medications, no documentation was found in the resident's electronic health record indicating that the activated Health Care Power of Attorney (HCPOA) had signed consents for these medications. The HCPOA confirmed via telephone that they had never signed consents for the use of these psychotropic medications. R26 was admitted with multiple complex medical conditions, including major depressive disorder and generalized anxiety disorder, for which the psychotropic medications were prescribed. The facility's Director of Social Services acknowledged that obtaining consents was primarily the responsibility of the nursing staff, with occasional assistance from social services. However, the surveyor's review revealed that the required consents were missing, and the facility was unable to provide any documentation of a Prozac consent. This deficiency was communicated to the facility's administration, including the Nursing Home Administrator and Director of Nursing, but no further information was provided to address the lack of consent documentation.
Failure to Provide Prior Notice for Room Changes
Penalty
Summary
The facility failed to provide prior written notice to four residents regarding room changes, as required by their policy. Resident 22 was moved to another room without prior notice or a choice of rooms, despite being cognitively intact and having expressed a desire to stay with their roommate. The move was reportedly due to safety concerns, but there was no documentation of the incidents leading to this decision, and the resident was not informed in advance. Resident 28, who is also cognitively intact, was transferred to another room without being given a choice or a documented reason for the move. The resident's bed was reportedly not working, but the Director of Social Services was unaware of the reason for the transfer, indicating a lack of communication and documentation regarding the room change. Residents 29 and 30, both with impaired decision-making abilities and activated Health Care Powers of Attorney (HCPOA), were transferred to new rooms without their HCPOAs being notified. Resident 29's move was due to a bed malfunction, but there was no documentation of notification to the HCPOA. Similarly, there was no documentation of the reason for Resident 30's transfer or notification to their HCPOA. These actions demonstrate a failure to adhere to the facility's policy of providing advance notice and involving residents or their representatives in room change decisions.
Failure to Report Alleged Neglect in a Timely Manner
Penalty
Summary
The facility failed to report an incident of alleged neglect involving a resident, identified as R24, to the State survey agency and the Nursing Home Administrator (NHA) within the required timeframe. R24, who is cognitively intact with a BIMS score of 15, reported to a surveyor that during the third shift, a CNA, identified as CNA-SSS, refused to assist her with using a bedpan despite her request due to diarrhea, and instead instructed her to use her diaper. R24 informed another CNA, identified as CNA-TTT, about the incident, but CNA-TTT did not report the allegation to the NHA or any other authority. The facility's policy mandates that any incident or suspicion of abuse, neglect, or mistreatment must be reported immediately to the administrator or a designated individual. However, when the surveyor inquired about the incident, the NHA was unaware of any such report. The NHA confirmed that staff are expected to report allegations of neglect, and upon learning of the incident from the surveyor, the NHA took steps to investigate and report it to the State Agency. The report highlights a failure in the internal reporting process, as the allegation was not communicated to the NHA or external authorities in a timely manner, as required by the facility's policy.
Failure to Report and Address Allegation of Neglect
Penalty
Summary
The facility failed to ensure the protection of a resident, identified as R24, following an allegation of neglect. On the night of the incident, R24 requested to be placed on a bedpan due to diarrhea, but the CNA on duty, identified as CNA-SSS, instructed R24 to use her diaper instead and left the room without assisting her. R24 reported this incident to another CNA, referred to as CNA-TTT, who apologized but did not report the allegation to the Nursing Home Administrator (NHA) or any other supervisory staff. This inaction allowed CNA-SSS to continue providing care for the remainder of the shift, contrary to the facility's policy that requires immediate removal of staff accused of neglect from resident contact. The facility's policy, titled 'Abuse Prevention Program,' mandates that any employee accused of abuse or neglect be removed from resident contact immediately and not return to work until the investigation is complete. However, this policy was not followed, as CNA-TTT failed to report the incident, and CNA-SSS continued to work with residents. The NHA was unaware of the incident until informed by the surveyor, indicating a breakdown in communication and adherence to the facility's internal investigation procedures. This deficiency highlights a failure in the facility's system to protect residents from potential neglect and ensure timely reporting and investigation of such allegations.
Failure to Implement Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as R27, who was diagnosed with moderate depression, among other conditions. Despite having a Patient Health Questionnaire (PHQ-9) score of 14, indicating moderate depression, and being prescribed medications such as Doxepin and Trazadone for depression, anxiety, and sleep, R27 did not have a mood/psychosocial needs care plan in place. The facility's policy requires that care plans be comprehensive, person-centered, and include measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. However, R27's care plan lacked specific interventions to address mood and psychosocial issues, despite the resident being treated by a psychologist since admission. The deficiency was identified during a surveyor's review of R27's electronic medical record and interviews with facility staff and the resident. The Social Services Director confirmed responsibility for completing sections of the resident's care plan, including mood and behavior, but acknowledged that the care plan should be updated as needed based on resident preferences. During an interview, R27 expressed feeling sad all the time and did not recall receiving a care plan with outlined goals and interventions. The surveyor shared these concerns with the facility's administration, but no further information was provided at the time.
Deficiencies in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, R25 and R27, leading to deficiencies in their care. R25, who has multiple diagnoses including hemiplegia and chronic kidney disease, was not provided with incontinence care for approximately five hours, resulting in a large yellowish-brown urine stain on her sheet. Despite her care plan indicating she should be checked and changed every two to three hours, staff did not adhere to this schedule. Observations by the surveyor confirmed that R25 had not been washed or had her incontinence product changed by 10:02 a.m., despite returning from the hospital at 5:18 a.m. R27, who has diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease, did not receive showers as per her preference and schedule. Although R27's MDS indicated that it was important for her to choose between different bathing options, she only received four showers since her admission, with no documentation of refusals or reapproaches for missed showers. The facility's policy required documentation of showers and refusals, but this was not consistently followed, leading to a lack of proper hygiene care for R27. Interviews with staff, including the DON and ADON, revealed inconsistencies in the documentation and execution of care plans for both residents. The facility's failure to adhere to its own policies and procedures for providing necessary care and maintaining documentation resulted in deficiencies in the quality of life and care for R25 and R27. The surveyor's findings highlighted the need for improved adherence to care plans and documentation practices to ensure residents receive the care they require.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of three residents, R15, R23, and R30, by not providing adequate supervision and assistance devices to prevent accidents. R15, who is at high risk for falls, did not have the necessary fall prevention interventions documented on the CNA Kardex. Despite a care plan intervention to keep the bed at transfer height, the bed was found in a low position after a fall on 1/15/2025. The Kardex used by CNAs did not include this critical intervention, leading to a lack of proper fall prevention measures. R23, who requires supervision during meals due to a risk of choking, was observed eating without supervision. The care plan, Kardex, and meal ticket all indicated the need for constant supervision, yet staff failed to follow these instructions. CNA documentation inaccurately recorded R23 as independent with meals for 16 out of 25 days, contradicting the required supervision interventions. R30 experienced an unwitnessed fall with injury on 1/15/2025, but the facility did not conduct a thorough investigation. A family member present at the time of the fall was not interviewed, and no witness statement was collected. The facility's failure to gather complete information and conduct a comprehensive investigation highlights a deficiency in their fall prevention and response procedures.
Failure to Provide Comprehensive Behavioral Health Services
Penalty
Summary
The facility failed to provide comprehensive behavioral health care and services to a resident, identified as R22, who has multiple diagnoses including Vascular Dementia, Major Depressive Disorder, Anxiety Disorder, ADHD, Alcohol Dependence, and Opioid Abuse. Despite significant behavioral changes, the facility did not offer necessary behavioral health services related to R22's substance abuse diagnoses. The facility's policy mandates that residents receive necessary behavioral health care to maintain their highest practicable well-being, but this was not adhered to in R22's case. R22's care plan documented various behavioral issues, including inappropriate phone calls, sexually inappropriate behavior, and mood problems. However, the facility did not update the care plan with new behaviors such as R22 banging their head on the headboard and expressing self-harm intentions. The facility also failed to conduct a root cause analysis of R22's escalating behaviors since November 30, 2024, and did not develop non-pharmacological interventions tailored to R22's needs. The facility's interdisciplinary team did not adequately communicate with R22's psychologist and psychiatrist about the resident's behaviors, nor did they complete an incident report for the self-harm behavior observed on January 17, 2025. The Director of Social Services was unaware of the new behaviors, and the Licensed Practical Nurse who observed the self-harm incident did not inform supervisors or complete necessary assessments. This lack of communication and failure to update care plans and conduct thorough assessments contributed to the deficiency in providing appropriate behavioral health services to R22.
Failure to Follow Medication Disposal and Administration Policies
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, identified as R26, by not following proper procedures for handling discontinued medications and ensuring timely administration of scheduled medications. R26 was discharged from the facility with discontinued medications, including Abilify, Prozac, and Zoloft, which were not supposed to be sent home. The facility's policy required that discontinued medications be removed from the medication cart and returned to the pharmacy, but this procedure was not followed. R26, who had a range of medical conditions including hypertensive heart disease, chronic kidney disease, diabetes, and vascular dementia, was cognitively intact and had an activated Health Care Power of Attorney during their stay. Despite the facility's policy that medications should be administered within 60 minutes of the scheduled time, R26's medications were administered late on 22 occasions between November 1 and November 26, 2024. The scheduled administration time was 6:30 AM, but the actual administration times varied significantly, with some doses given as late as 1:51 PM. Interviews with facility staff revealed inconsistencies in understanding the policy for medication administration timing. Some staff believed medications could be administered up to two hours late, while others stated a 30-minute window. The surveyor noted a lack of documentation in R26's medical record regarding the late administration of medications. The facility's failure to adhere to its own policies for medication disposal and administration contributed to the deficiencies identified during the survey.
Failure to Provide Resident with Meal Preferences and Required Dietary Items
Penalty
Summary
The facility failed to provide a resident, identified as R27, with food accommodations and preferences as listed on their meal tickets. On a specific date, R27 did not receive the preferred items for breakfast, including a banana, coffee, hot cereal, water, and Nepro, which were listed on the meal ticket. R27, who is cognitively intact and has multiple diagnoses including Type 2 Diabetes Mellitus and End Stage Renal Disease, expressed that they frequently do not receive meal preferences and have to order food from outside. The resident's physician had ordered Nepro with meals to aid in weight stability and healing, but it was not provided. The Dietary Manager and Registered Dietitian confirmed that R27 did not receive the items listed on the meal ticket. The Dietary Manager explained that CNAs are responsible for placing liquids on trays but are not reading the meal tickets properly. The issue was acknowledged as a problem with both CNAs and Dietary Aides not ensuring that residents receive the correct items. The concern was shared with the Nursing Home Administrator and other facility leaders, but no additional information was provided by the facility at that time.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and PPE usage. During incontinence care for a resident with hemiplegia and other health conditions, staff members did not perform hand hygiene appropriately. One staff member wore two pairs of gloves, and another did not remove gloves or perform hand hygiene after handling soiled items. This was contrary to the facility's policy, which requires hand hygiene after contact with body fluids and removal of gloves. In another instance, the facility's wound nurse did not perform hand hygiene during a wound treatment observation for a resident on enhanced barrier precautions. The nurse placed soiled dressings on a device in the room and left to get a garbage bag without washing hands. Upon returning, the nurse continued the treatment without performing hand hygiene after removing gloves, which is against the facility's infection control policy. Additionally, the Nursing Home Administrator entered a resident's room, who was on isolation for COVID-19, without donning appropriate PPE, including a mask, gown, gloves, and eye protection. The administrator also failed to perform hand hygiene upon exiting the room. This was a direct violation of the facility's COVID-19 infection control guidance, which mandates PPE use and hand hygiene to mitigate the risk of disease transmission.
Failure to Ensure Resident Safety and Proper Investigation of Falls
Penalty
Summary
The facility failed to ensure the safety of several residents, leading to accidents and injuries. One resident, R12, was transferred using a pivot transfer instead of the required Hoyer lift, resulting in a laceration that required 17 stitches. The staff involved did not verify the correct transfer method as per the care plan, and there was a lack of clarity on what caused the injury during the transfer. The facility's investigation did not identify the cause of the injury, and the staff involved were not fully aware of the resident's transfer needs. Another resident, R14, experienced multiple falls that were not thoroughly investigated. The falls occurred over several days, and the care plan was not updated promptly to address the risks. The facility did not collect staff statements or determine when the resident was last observed or toileted before the falls. The lack of timely intervention and investigation into the falls contributed to the ongoing risk of harm to the resident. Similarly, R15 experienced several falls that were not adequately investigated. The facility failed to conduct thorough investigations, including obtaining staff statements and determining the root cause of the falls. The care plan was not revised in a timely manner to address the resident's fall risk. Additionally, the facility did not ensure the proper placement of a Wanderguard bracelet, which could interfere with its function, further compromising the resident's safety.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, particularly in the dining areas and hallways. Observations revealed that the dining areas on the first floor, 2 South, and 2 West were consistently unclean, with dried food debris, stains, and other unsanitary conditions present on tables, floors, and furniture. These conditions persisted despite the presence of residents eating meals in these areas, indicating a lack of timely cleaning and maintenance. Housekeeping staff were not present after dinner to clean the dining areas, leading to residents eating in unclean environments the following morning. Interviews with staff, including housekeeping and CNAs, highlighted a disconnect in responsibilities and communication regarding the cleaning of dining areas. Housekeeping staff reported arriving after residents had already begun eating breakfast, and there was confusion about which department was responsible for cleaning after meals. The Housekeeping Director acknowledged the presence of debris from previous days and indicated that education would be provided to staff, but the issue persisted over multiple days of observation. Additional observations included brown water stains on ceiling tiles in hallways, scattered cereal on a piano and bench, and metal pieces protruding from walls where pictures had been removed. These findings suggest a broader issue with maintenance and cleanliness throughout the facility. Interviews with the Maintenance Director revealed a lack of awareness of these issues, and there was no immediate action taken to address them. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies, but no further information was provided on corrective actions taken.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming, specifically in the area of bathing. Two residents, identified as R15 and R11, did not consistently receive showers or bed baths as required by the facility's policy. The policy mandates that all residents are offered a bath or shower at least twice a week, and if a resident refuses, the refusal must be documented by the licensed nurse. However, there was no documentation of refusals or alternative bathing methods provided for the missed dates. R15, who has diagnoses including peripheral vascular disease, diabetes mellitus, coronary artery disease, bipolar disorder, and vascular dementia, was assessed as requiring substantial assistance for bathing. Despite this, R15 did not receive scheduled showers or bed baths on multiple occasions, and there was no documentation of refusals or interventions in the medical record. Interviews with staff revealed that R15 was particular about who assisted with bathing, but this preference was not accommodated after the departure of the preferred staff member. R11, who was admitted with conditions such as interstitial lung disease, congestive heart failure, hypertension, and end-stage renal disease, also did not receive a scheduled shower. The CNA Kardex did not specify R11's scheduled shower days, and there was no physician order for bathing. Despite being scheduled for a bed bath on a specific date, there was no documentation of a shower or bath on another scheduled day. The lack of documentation and adherence to the bathing schedule for both residents indicates a deficiency in the facility's care practices.
Failure to Maintain Oxygen Humidification for Resident
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident receiving oxygen therapy. The resident, who has diagnoses including congestive heart failure, chronic respiratory failure with hypoxia, dementia, and anxiety, was observed with an empty oxygen humidification bottle. The facility's policy requires that humidifier bottles be filled with sterile distilled water as needed to maintain the proper level, but this was not adhered to in the case of the resident. The resident's care plan and physician orders specified the use of oxygen therapy at 4 liters per minute, yet the humidifier bottle was found dry during multiple observations by the surveyor. The resident indicated a preference for tap water in the humidifier bottle, citing a dislike for the smell of chemicals, and mentioned that the bottle had been empty for a significant period. Despite the resident's condition and the facility's policy, staff, including an LPN and the ADON, acknowledged that the humidifier bottle should contain water but failed to ensure it was filled. The deficiency was communicated to the facility's administration, including the NHA, DON, Regional Director, and Director of Quality Assurance, but no explanation was provided for the oversight.
Facility Fails to Maintain Legible Nurse Staffing Documents
Penalty
Summary
The facility failed to maintain legible nurse staffing documents for a period of 39 days, potentially affecting all 101 residents residing in the facility. The Nurse Staff Posting form, which is intended to inform staff, residents, and visitors about the amount of direct care staff currently working, was found to be illegible. The form contained black specks, extra lines, and was slanted, making it difficult to read. This issue was observed by the surveyor on multiple dates, and the facility's Staffing Contingency Policy did not address the requirement for legible documentation. During an interview, the scheduler acknowledged the difficulty in reading the form and was unsure of how to obtain a new copy, as copies were routinely placed at the front desk. The issue was not addressed until the surveyor brought it to the attention of the Nursing Home Administrator and Director of Nursing, who were unaware of the problem prior to the survey. The facility replaced the form with a legible version only after the surveyor's intervention, indicating a lack of proactive measures to ensure compliance with documentation standards.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to ensure comprehensive assessment and care planning for three residents, leading to the development and deterioration of pressure injuries. Resident 1 was admitted without any pressure injuries but was at risk due to conditions such as diabetes and impaired mobility. Despite being identified as at risk, the facility did not implement preventive measures like heel offloading until after a blister developed on the resident's heel. The blister was inaccurately assessed, and the care plan was not updated to address noncompliance with treatment until much later, resulting in the injury worsening to a Stage 4 pressure injury with osteomyelitis, requiring hospitalization. Resident 2 was found with pressure injuries on both feet, but the care plan was not updated promptly, and treatment was delayed. During a surveyor's observation, one of the pressure injuries was incorrectly staged, indicating a lack of adherence to professional standards of practice. The facility's failure to update care plans and initiate timely treatment contributed to the residents' conditions worsening. Resident 3's pressure ulcers were not staged according to standards during wound treatment care, and the facility did not follow the skin monitoring interventions listed in the care plan. The facility's policies required interventions to prevent pressure ulcer development and deterioration, but these were not effectively implemented, leading to actual harm to the residents.
Removal Plan
- Residents at risk for pressure injuries were identified and person-centered care plans were established to ensure preventative measures.
- Education was provided to nursing and IDT on following the facility's wound management policy including the requirement of a comprehensive RN assessment of any newly identified pressure injuries and updating care plans.
- All nursing and IDT staff will be educated on the importance of implementing person centered care plans for the prevention of pressure injuries.
- All Nursing staff and IDT will be educated on documentation of Risk vs Benefit conversation and documentation for any non-compliance.
- The facility policy and procedure on wound management and coordination was reviewed with the medical director. Including RN assessment and care plan updates to ensure policy meets current standard of practice.
- IDT will meet weekly to audit residents at risk for pressure injuries to ensure preventative interventions are in place, care plans are updated, and weekly skin checks are documented.
- IDT will review daily in clinical meeting any new admissions assessments, incidents regarding skin, and document on eagle board to ensure proper assessments have been obtained and notifications have been made.
- Ad hoc QAPI is scheduled.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent the elopement of a resident, identified as R5, who was at risk for elopement. R5 was admitted with a Wanderguard due to exit-seeking behaviors and was assessed as a non-smoker. On a particular day, R5 cut off the Wanderguard, and a new Elopement Risk Assessment indicated a higher risk for elopement than the initial assessment. Despite this, the facility staff decided that R5 did not require the Wanderguard, and no additional supervision was implemented. R5 was also documented as an active smoker by a Psychiatric Nurse Practitioner, but the facility did not assess R5 for smoking safety or supervision, nor did they initiate a care plan for smoking. On the day of the incident, R5 was last seen smoking on the facility grounds at 1 PM. Later, when a Licensed Practical Nurse went to administer medications at 6 PM and again at 8 PM, R5 was not in his room. A search was initiated, and the police were called at 10:40 PM. A silver alert was issued the following morning, and R5 was found by police at his former apartment, 17 miles away from the facility. The facility's failure to provide adequate supervision and interventions for R5's elopement risk created a finding of immediate jeopardy. The facility's policy on elopement prevention was not followed, as R5's exit-seeking behaviors were not adequately monitored or documented. Staff interviews revealed that R5 exhibited exit-seeking behaviors from the beginning of his stay, but these were not reflected in the medical records. Additionally, R5's refusal of medications such as Seroquel and Zoloft was not communicated to the Psychiatric Nurse Practitioner after the initial visit, and the Zoloft medication order was delayed. The facility's lack of documentation and failure to implement a comprehensive care plan for R5's known risks contributed to the deficiency.
Deficiencies in Wound Care and Lab Result Reporting
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, R4 and R6, according to professional standards and the residents' care plans. R4, who was admitted with a midline surgical incision, did not receive a comprehensive assessment or monitoring for the incision. Despite being admitted for wound management, there were no care plans or orders initiated to monitor R4's surgical incision until after R4 was hospitalized for an infection. Upon readmission, R4's wound care orders were delayed, and the care plan was not revised promptly, leading to another hospital transfer due to a possible infection. R6 experienced a change in condition, but the facility failed to act upon ordered labs and results in a timely manner. R6 was admitted with several diagnoses, including congestive heart failure and diabetes mellitus. After R6 complained of emesis, a CBC and BMP were ordered, but the results, which indicated significant abnormalities, were not reported to a physician until the following day. This delay in reporting led to R6 being sent to the hospital for further treatment. The facility's policies on wound management and change of condition were not followed, resulting in inadequate monitoring and documentation for both residents. Interviews with staff revealed inconsistencies in the implementation of care plans and communication of critical information, contributing to the deficiencies observed by the surveyor.
Deficiency in Foot Care for Residents
Penalty
Summary
The facility failed to provide appropriate foot care for two residents, R1 and R3, as observed by the surveyor. R1, who has type 2 diabetes, obesity, and spinal stenosis, was found to have long toenails in need of trimming during a wound care observation. There was no evidence in R1's medical record of a podiatrist visit for nail trimming, and the facility lacked a policy for diabetic foot care. Despite the surveyor's inquiry, no additional information regarding R1's foot care was provided by the facility. R3, who has cerebral infarction, end-stage kidney disease, peripheral vascular disease, and diabetes mellitus type 2, also exhibited long, thick, and unkempt toenails. R3's care plan included interventions for proper foot care, but these were inconsistently implemented. The facility's Treatment Administration Record showed missed daily diabetic foot checks on specific dates, and R3 did not receive diabetic nail care until observed by the surveyor. The Acting DON confirmed that R3 had not had a recent podiatry consult and lacked a diabetic foot care plan. No additional information was provided to explain the lack of daily diabetic foot care as per R3's plan.
Failure to Provide Adequate Social Services for Resident with Depression
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R5, to help them achieve the highest possible quality of life. R5 was admitted with several diagnoses, including moderately severe symptoms of depression, but the facility did not develop a care plan with resident-centered interventions and monitoring for R5's mental and psychosocial well-being. Despite R5's verbalization of a desire to leave the facility and an elopement incident, the facility did not document any follow-up on the discharge planning evaluation, which was vague and inconclusive. R5's medical records indicated a severely impaired cognition with a BIMS score of 6 and a PHQ9 score of 15, reflecting moderately severe depression. The facility's initial psychiatric evaluation noted R5's resistance to medication and behaviors such as barricading the door, yet no care plan addressing R5's depression was initiated. The discharge planning evaluation completed by the social worker was marked as uncertain, with no clear goals or plans for R5's discharge, and no follow-up was documented. Interviews with facility staff revealed that R5 frequently expressed a desire to leave the facility, and staff were aware of R5's exit-seeking behavior. Despite this, the facility did not make referrals to other facilities, as R5's guardian wanted R5 to remain at the facility. The facility's inaction in addressing R5's mental health needs and discharge planning contributed to the deficiency in providing adequate social services to R5.
Medication Administration and Communication Failures
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the delayed administration of prescribed medications and lack of communication with the prescribing nurse practitioner. The resident, who had a history of dementia, depression, and anxiety, was evaluated by a psychiatric nurse practitioner who recommended the continuation of Seroquel and the initiation of Zoloft. However, the facility did not enter the Zoloft order until six days after the recommendation, and the resident refused multiple doses of both medications without documentation that the nurse practitioner was informed of these refusals. Additionally, the facility did not properly address the resident's medical needs following an emergency room visit. The hospital's After Visit Summary indicated that the resident should begin blood sugar testing and insulin administration due to a diagnosis of Type 2 diabetes mellitus. The facility failed to acknowledge these instructions, did not document any communication with the resident's primary physician regarding the new diagnosis and treatment plan, and did not implement the necessary medical interventions. Interviews with facility staff revealed inconsistencies in the process of reviewing and implementing hospital discharge instructions. The Director of Nursing and other staff members were unaware of the resident's diabetes diagnosis and the need for insulin, indicating a breakdown in communication and documentation. The facility's policies on medication administration and refusal reporting were not followed, contributing to the resident's exposure to significant medication errors.
Inadequate Coordination of Hospice Services for Two Residents
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for two residents, R3 and R2, leading to inconsistencies in care and communication. For R3, the facility did not designate a staff member as the interdisciplinary group (IDG) member to coordinate hospice care, as required by their hospice contract. This lack of coordination resulted in confusion about wound care responsibilities, with discrepancies between hospice and facility staff regarding who was responsible for R3's wound treatments. Hospice staff and facility nurses provided conflicting information about the wound care schedule and documentation, leading to inadequate communication and documentation of R3's wound care needs. For R2, the facility failed to maintain accurate and timely documentation of hospice visits and wound care assessments. The hospice visit notes were not updated in R2's medical record until requested by the surveyor, and hospice staff were unaware of pressure injuries on R2's feet. Despite the facility notifying hospice of these injuries, hospice staff denied knowledge of them during interviews. The facility's failure to ensure that hospice was actively involved in R2's wound care and assessments resulted in a lack of coordinated care for R2's pressure injuries. Overall, the facility's deficiencies in coordinating hospice services and maintaining accurate documentation led to inconsistent and unprofessional care for residents R3 and R2. The lack of communication and coordination between hospice and facility staff contributed to inadequate wound care management and documentation, ultimately impacting the quality of care provided to these residents.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, specifically for a resident with significant weight changes. The resident, who had multiple diagnoses including hypertensive heart and chronic kidney disease with heart failure, experienced weight fluctuations that were outside the parameters set by the physician. Despite these changes, the facility did not notify the physician as required by their policy. The facility's policy on change in condition and weight management requires immediate notification to the physician for significant weight changes. However, the resident's weights were not monitored daily as ordered, and significant weight changes on specific dates were not communicated to the physician. Interviews with facility staff revealed inconsistencies in the process of obtaining and reporting weights, with some staff believing that weights were only required on dialysis days or according to different schedules. The deficiency was identified through interviews and record reviews, which showed that the facility did not adhere to its own policies or the physician's orders regarding weight monitoring and notification. The failure to update the physician about the resident's weight changes and to obtain daily weights as ordered contributed to the deficiency noted by the surveyors.
Inadequate Supervision Leads to Resident Aggression
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for three residents, leading to incidents of verbal and physical aggression. Resident R4, who has a history of verbal aggression and physical altercations, was not adequately supervised when interacting with other residents. R4's care plan noted his potential for aggression due to dementia and other conditions, yet he was observed self-propelling in his wheelchair without staff supervision, leading to altercations with residents R3 and R12. On multiple occasions, R4 exhibited aggressive behavior, including yelling profanities and physically hitting another resident, R3. Despite these incidents, staff did not consistently monitor or document R4's behaviors as expected. Interviews with staff revealed that while they were aware of R4's tendencies, they did not always report or document verbal interactions unless they escalated to physical altercations. This lack of consistent monitoring and documentation contributed to the deficiency in providing adequate supervision. The facility's staff, including the Director of Activities and nursing staff, acknowledged R4's aggressive behaviors but did not consistently communicate these incidents to the appropriate personnel. The Director of Nursing and other staff members expressed expectations for monitoring and documentation that were not met, indicating a gap in communication and adherence to care plans. This failure to ensure proper supervision and documentation of R4's behaviors resulted in a deficiency in maintaining a safe environment for all residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions. Surveyors noted the presence of brown material resembling bowel movement on the walls and floors of bathrooms, as well as food particles, dirt, and debris under beds and on floors in several resident rooms. These conditions persisted over multiple days, indicating a lack of timely cleaning and maintenance. Additionally, broken fixtures such as window blinds and toilet paper holders were observed, further contributing to the unkempt environment. In the dining and common areas, surveyors found missing ceiling tiles, food debris on floors, and stained carpets and curtains. The main lobby had a persistent sewage smell, and the exterior of the building was unkempt with overgrown grass and weeds. The facility's housekeeping staff appeared to be insufficiently staffed or unable to address these issues effectively, as evidenced by the repeated observations of the same deficiencies over several days. The facility's failure to address these environmental concerns was further highlighted by the surveyor's interactions with housekeeping staff and the Housekeeping Director, who acknowledged the issues but had not yet resolved them. The lack of adequate cleaning and maintenance not only compromised the residents' right to a safe and homelike environment but also reflected poorly on the facility's overall management and operational standards.
Deficiencies in Wound Care and Treatment Administration
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice for non-pressure wounds. One resident with a surgical wound to the back had a treatment order for a wound vac that was not transcribed correctly into the Treatment Administration Record (TAR). The treatment orders had conflicting administration times that were not clarified, and treatments were not consistently signed out as being administered. Additionally, the wound vac pressure setting in the TAR was incorrect, and the treatment ordered after the wound vac was discontinued had conflicting administration times. Another resident with multiple Moisture Associated Skin Damage (MASD) wounds had multiple treatments ordered to the same area without clarification on which treatment was correct. A new non-pressure wound was identified, but the order was not entered onto the TAR for nursing to sign out when administered. The resident reported having sores on their skin, but the treatments were not consistently documented or clarified. A third resident was observed with an undated bandage on the right second toe, which was saturated with bloody drainage. There was no assessment of this toe prior to the bandage being applied, and no notification to the physician was documented. Lastly, a resident did not receive a bladder scan according to physician's orders, as the scan was not completed and the TAR was not initialed as being completed. The facility's Director of QA acknowledged the issue when informed by the surveyor.
Failure to Complete Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident who expressed a desire to self-administer medication was properly assessed to determine their capability to do so. The resident, identified as R99, has diagnoses including osteomyelitis of the vertebra, anxiety disorder, and depression, and was found to be cognitively intact with a BIMS score of 15. Despite the resident's request to self-administer medication due to perceived medication errors, the facility did not complete the necessary assessment. A medication self-administration evaluation was initiated but left incomplete, with critical sections and approvals missing. The resident reported not receiving medications for self-administration despite being given a key for storage. The LPN was unsure if the assessment was completed, and the medical record review confirmed the assessment was incomplete. A statement from the resident's new physician indicated safety concerns for self-administration, but the resident had not been consulted by either the previous or current physician regarding this matter. The surveyor informed the facility's administration of the deficiency, highlighting the lack of a completed assessment for the resident's ability to self-administer medication.
Failure to Ensure Resident Privacy During Toileting
Penalty
Summary
The facility failed to ensure personal privacy for a resident during a toileting observation. The incident involved a resident with severe cognitive impairment, who required assistance for toileting hygiene and transfers. During the observation, a CNA assisted the resident into the bathroom but was unable to close the bathroom door. Additionally, the privacy curtain for the resident's roommate was not closed, allowing the roommate to see the resident on the toilet. The CNA did not take steps to ensure the resident's privacy by closing the room door or the privacy curtain. The facility's policy on privacy and confidentiality emphasizes treating residents with respect and ensuring privacy in personal care. However, during the incident, the CNA did not adhere to this policy, resulting in a breach of the resident's privacy. The surveyor observed the situation and later informed the LPN, DON, and other facility leaders about the deficiency, highlighting the failure to provide personal privacy to the resident during toileting.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances filed by two residents, R501 and R99, as required by their grievance policy. R501 filed three grievances, but there was no evidence to confirm whether the grievances were addressed or if R501 was informed of any corrective actions taken. The grievance forms lacked essential information such as the date received, staff involved, and confirmation of the grievance. Additionally, the forms were signed by the Nursing Home Administrator (NHA) instead of R501, indicating a lack of proper documentation and communication with the resident. Similarly, R99 filed multiple grievances, but there was no documentation to confirm whether these grievances were resolved. The grievance forms for R99 also lacked signatures from the Director of Nursing and did not indicate whether the grievances were confirmed or resolved. R99 reported that some grievances were submitted in writing, but the NHA did not retain the original documents, opting instead to transcribe the issues onto the facility's grievance form. This practice led to incomplete records and a lack of clarity on whether the grievances were addressed satisfactorily. Both residents had intact cognitive function, as indicated by their BIMS scores, suggesting they were capable of understanding and participating in the grievance process. However, the facility's failure to follow its grievance policy and maintain proper documentation resulted in unresolved grievances and a lack of communication with the residents. The NHA's practice of signing the grievance forms in place of the residents further contributed to the deficiency, as it obscured whether the residents were informed of the outcomes or agreed with the resolutions.
Deficient Discharge Planning for Diabetic Education
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, identified as R501, who was reviewed for discharge planning. R501, who was living independently in the community, suffered a fall and was hospitalized with a subdural hematoma, fractures, and an elevated A1C, leading to a new diagnosis of diabetes and the initiation of insulin therapy. Despite the resident's goal to return to the community, the facility did not provide necessary diabetes education, including blood sugar monitoring and medication administration, to prepare R501 for discharge and prevent readmission. R501's care plan included interventions for diabetes management, such as educating the resident and family about medications, glucose monitoring, and insulin injections, and ensuring the resident could demonstrate these skills. However, the facility's Medication Administration Record and Treatment Administration Record did not document any education or return demonstrations related to diabetic management. Interviews with facility staff, including the Social Service Director and Director of Nursing, revealed a lack of awareness and documentation regarding whether the necessary diabetes education was provided to R501 before discharge. The discharge paperwork provided to R501 lacked documentation of blood sugar testing training and medication administration teaching. The Director of Nursing could not confirm if such education was completed, indicating a deficiency in the facility's discharge planning process. This oversight was noted by the surveyor, who informed the Nursing Home Administrator, Director of Nursing, and Chief Innovations Officer of the findings.
Inconsistent Bathing Schedule for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R99, received the necessary services to maintain their ability to practice good grooming and personal hygiene. The facility's policy mandates that residents are offered a bath or shower at least twice a week, with documentation required for each instance. However, R99, who is cognitively intact and requires supervision or assistance for bathing, reported not receiving showers as scheduled. The facility's records corroborated this, showing inconsistencies in the documentation of R99's showers over several weeks, with instances of only one shower per week or no documentation at all. R99's medical history includes osteomyelitis of the vertebra, sacral & sacrococcygeal region, anxiety disorder, and depression. Despite being assessed as not refusing care, the facility's documentation did not reflect consistent adherence to the bathing schedule. The Director of Nursing (DON) and Director of Quality Assurance (QA) were unaware of any complaints or refusals from R99 regarding showers. The surveyor's investigation revealed a lack of documentation and communication regarding R99's bathing schedule, highlighting a deficiency in the facility's adherence to its own policies.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevention for two residents, R67 and R53, as observed by surveyors. R67, who has diagnoses including hypertension, dementia, and anxiety disorder, was identified as at risk for pressure injuries. Despite the care plan specifying the use of a pressure-relieving cushion in the wheelchair, R67 was repeatedly observed without one over several days. This oversight was confirmed by staff, including the LPN and DON, who acknowledged the requirement for a cushion in the wheelchair according to the care plan. R53, diagnosed with multiple sclerosis, vascular dementia, and hypertension, had a Stage 3 pressure ulcer on the right ischium. The facility failed to correctly transcribe and implement the wound care orders from the Wound Physician. The treatment plan was not updated in a timely manner, resulting in the continued use of outdated treatments. Additionally, R53 was observed without pressure-relieving boots, which were part of the care plan to prevent further skin breakdown. The surveyor's observations highlighted significant lapses in adhering to the care plans and physician orders for both residents. These deficiencies in pressure ulcer management and prevention were not addressed promptly, as evidenced by the delayed implementation of updated treatment orders and the absence of prescribed pressure-relieving devices. The facility's failure to follow professional standards of practice contributed to the risk of pressure injury development and hindered the healing process for the affected residents.
Inadequate Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention measures for two residents, R67 and R53, leading to deficiencies in their care. R67, who is at high risk for falls due to conditions such as hypertension, dementia, and seizure activity, was observed being transferred without the use of a gait belt by CNAs. Despite the facility's policy requiring the use of gait belts for residents needing assistance with transfers, staff members CNA-M and CNA-P were seen assisting R67 without this safety measure, which was confirmed by their own admissions and the observations of the surveyor. R53, diagnosed with multiple sclerosis, vascular dementia, and anxiety disorder, was also subject to inadequate safety measures. The resident's care plan required the bed to be kept in the lowest position and the call light to be within reach, yet these interventions were not consistently followed. Observations revealed that R53's bed was often left in a high position, and the call light was repeatedly found on the floor or out of reach, contrary to the care plan's directives. This lack of adherence to the care plan was noted over several days and confirmed by staff interviews. The surveyor's findings highlighted a pattern of non-compliance with established safety protocols for both residents. Despite the facility's policies and care plans designed to mitigate fall risks and ensure resident safety, the observed practices demonstrated a failure to implement these measures effectively. The deficiencies were communicated to the facility's administration, including the Nursing Home Administrator, Director of Nursing, and other key personnel.
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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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