Ascension Living - Lakeshore At Siena
Inspection history, citations, penalties and survey trends for this long-term care facility in Racine, Wisconsin.
- Location
- 5643 Erie Street, Racine, Wisconsin 53402
- CMS Provider Number
- 525495
- Inspections on file
- 26
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Ascension Living - Lakeshore At Siena during CMS and state inspections, most recent first.
Surveyors found that the facility failed to thoroughly assess multiple resident falls and did not promptly individualize fall-prevention care plans. Cognitively intact residents with conditions such as diabetes, COPD, stroke, orthostatic hypotension, and Alzheimer’s had unwitnessed and witnessed falls during toileting, in bed, and during transfers, including events that resulted in fractures and hospital transfers. Post-fall documentation often lacked root cause analysis, omitted key details (such as incontinence, footwear, or environmental factors), and left intervention sections blank. Therapy recommendations for transfer assistance were not timely incorporated into ADL care plans, leading to staff confusion and use of incorrect transfer methods. CNA worksheets, derived from non-individualized care plans, listed multiple or conflicting transfer instructions, and staff interviews showed uncertainty about who was responsible for updating care plans after falls.
Multiple residents were not comprehensively assessed or treated according to professional standards and facility protocols. One resident with antibiotic-associated diarrhea developed macerated skin on the buttocks that was not fully assessed or reported to a provider, while an antifungal powder from a prior hospitalization was applied without an order and by a CNA. Another resident admitted with right leg cellulitis and multiple diabetic and non-pressure ulcers had no descriptive documentation of the cellulitis, and an order to cleanse and apply betadine did not specify the treatment site. A resident on Xarelto had an unwitnessed fall from bed onto an overbed table, with abrasions, hypotension, and altered mental status; staff moved the resident with a mechanical lift and called a private ambulance instead of 911, and the NP was not given vital signs. A hospice resident with an unwitnessed fall and severe back pain did not receive neurological checks at the frequencies required by the facility’s neuro assessment protocol. Another resident with a new skin wound did not receive a comprehensive wound assessment or the ordered wound consult, and after an unwitnessed fall while on blood thinners, did not receive a thorough post-fall neurological assessment.
A facility failed to administer medications timely and as ordered for multiple residents, including one with severe cognitive impairment and generalized anxiety disorder whose scheduled hydroxyzine was repeatedly given outside the facility’s 1-hour administration window, was unintentionally discontinued for two days, and later continued to be administered late or omitted after being restarted. Other residents received morning medications, including statins, antidepressants, analgesics, and anticoagulants, more than two hours after scheduled times, and one resident’s IV cefepime regimen for a catheter-associated UTI included missed initial doses due to pharmacy delay, a dose given over five hours early, and several doses not signed out at all. Staff interviews revealed uncertainty about who reviews provider assessments and uploads them into charts, and nurses reported workload issues and documentation gaps despite a facility policy requiring medications to be given within 60 minutes before or after the ordered time.
Two residents were involved in an incident where a confused resident entered another resident’s room, grabbed the resident’s forearm, and caused pain and fear; although this was documented in the EHR and leadership was notified, no facility‑reported incident or investigation could be produced. In a separate event, the same resident was later found with a head abrasion of unknown origin; the facility’s investigation lacked factual findings, did not include interviews with the CNA and LPN who first identified and documented the injury, and was initiated several days after the injury was discovered, contrary to facility policy requiring prompt reporting and investigation of alleged abuse and injuries of unknown origin to appropriate authorities.
The facility failed to conduct timely and thorough investigations into a resident-to-resident altercation and a head injury of unknown origin. In one incident, a confused resident entered another resident’s room, grabbed the resident’s forearm, and caused pain and fear; although staff intervened and notified leadership, no investigation or Facility Reported Incident documentation could be produced. In a separate event, the same confused resident was later found with a head abrasion during a skin check, but the investigation began three days after discovery, omitted interviews with the CNA and LPN who first identified and documented the injury, and left the factual findings section blank, contrary to facility policy requiring comprehensive, immediate investigations.
Surveyors identified a 30% medication error rate when two residents received multiple medications outside the facility’s 60-minute administration window and one extended-release potassium tablet was improperly split. One RN gave tramadol and omeprazole significantly later than the ordered time, and another RN administered several scheduled morning medications, including atorvastatin, Vitamin D3, sertraline, Tylenol, propranolol, potassium ER, and Eliquis, well past the allowed time frame while also breaking the potassium ER tablet in half, contrary to its extended-release design.
The facility failed to consistently maintain and accurately update daily nurse staffing postings. Several required daily postings were missing, and on two occasions the NOC shift postings listed more CNAs than were actually scheduled. The staff member responsible for updating postings acknowledged that the information should have been corrected and that the missing postings should have been available, resulting in inaccurate posted information about licensed staff directly responsible for resident care for all residents.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors.
A resident's allegation of abuse by a CNA was not documented as reported to the State Survey Agency within the required two-hour timeframe. The facility's incident report remained in draft status with missing submission details, and there was no verifiable evidence that the initial report was made promptly, as required by policy.
A resident with a diabetic foot ulcer did not have a complete medical record after the facility changed wound care providers and lost access to the previous provider's documentation. The facility was unable to provide the wound assessments from the former contracted wound MD, resulting in missing clinical records for the resident.
The facility failed to ensure the safety of two residents from accidents and hazards. One resident experienced multiple falls without appropriate risk assessments or interventions, while another was struck by a Hoyer lift during a transfer, with the incident going unreported and without preventive measures. These deficiencies highlight the facility's inability to adequately supervise and protect residents.
A resident with Alzheimer's and chronic pain experienced discrepancies in their medication administration records. The MAR showed fewer administrations of Morphine than the controlled drug log, with the actual administration documented more times than reflected in the MAR. Interviews with staff revealed late entries and inconsistencies in documentation, leading to inaccurate records.
A resident with chronic conditions developed pressure injuries on both heels due to the facility's failure to timely revise care plans and conduct comprehensive assessments. Despite having a policy for pressure injury management, the facility did not adhere to it, resulting in the resident's left heel injury worsening to an unstageable ulcer. Interviews revealed gaps in documentation and communication among staff.
Two dishwashing machines in the facility's unit kitchens were leaking water onto the floor, and one lacked a functioning temperature display, posing potential hazards. The issues were acknowledged by the Dietary Manager, who mentioned a maintenance request was submitted. However, the Director of Facilities had not formally requested service until prompted by the surveyor, and a part was awaited for repairs. These deficiencies potentially impacted all 24 residents on the affected units.
Two residents at the facility did not have their Do Not Resuscitate (DNR) forms in their medical records, contrary to facility policy. One resident, with impaired cognition and an activated power of attorney, and another cognitively intact resident, both lacked the necessary documentation. The facility's administration was unable to locate the forms and was in the process of obtaining new signed forms.
A resident's visitation rights were restricted after an alleged abuse incident involving a family member. The facility required supervised visits but failed to provide supervision on weekends, limiting access. The administration did not communicate visitation requirements to the family member, and the social worker did not document or assess the impact of restricted visits on the resident.
A resident with a history of cerebral infarction and other conditions was improperly transferred using a Hoyer lift by a single staff member, contrary to the care plan requiring two staff members. This resulted in a bruise on the resident's forearm, exacerbated by medications increasing bleeding risk. The facility's investigation confirmed the neglect in following the care plan.
A resident experienced verbal and physical abuse by a family member, which was not reported to the NHA or State Agency within the required timeframe. The facility's staff, including an RN and CNAs, witnessed the abuse but delayed reporting it. Additionally, an allegation of neglect involving the resident being left in a wheelchair for 40 hours was not reported, as the RN dismissed it as implausible. These incidents were identified during a survey, revealing deficiencies in the facility's reporting procedures.
A facility failed to thoroughly investigate allegations of verbal and physical abuse, as well as neglect, involving a resident. The verbal abuse by the resident's daughter was not fully explored, and the physical abuse allegation was not investigated until a month later. Additionally, a neglect claim that the resident was left in a wheelchair for 40 hours was dismissed by an RN without proper investigation or documentation.
A resident with Alzheimer's Disease experienced restricted visitation with a family member after alleged abuse, but the facility failed to assess or monitor the impact on the resident's well-being. The social worker did not document interactions or update the care plan, and the family was not informed about visitation requirements, violating the facility's social services policy.
The facility failed to promptly resolve grievances for four residents, including issues with not being dressed, not getting out of bed until the second shift, and not receiving showers. The facility did not follow up with the residents or their representatives and did not document the date written decisions were issued, violating their grievance policy.
A resident with multiple diagnoses, including Parkinson's Disease and CKD, did not receive consistent assistance with showering as per their care plan. Documentation showed gaps and inconsistencies in the provision of showers, and staff interviews revealed a lack of awareness and recollection regarding the resident's needs.
A resident with multiple diagnoses, including stroke and diabetes, experienced significant weight loss, but the facility failed to obtain weekly weights as ordered by the physician over an eleven-week period. Despite the facility's weight monitoring policy, the required weekly weights were not documented on several occasions.
Failure to Perform Root Cause Analysis and Individualize Fall Prevention After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, thorough post-fall assessments, and timely, individualized care plan revisions to prevent accidents for multiple residents reviewed for falls. The facility’s own fall policy required completion of a fall risk assessment after every fall, evaluation of the area where the fall occurred for possible contributors, documentation of identified interventions, and 72-hour observation after a fall. However, for several residents, falls were not thoroughly assessed to determine root causes, contributing factors such as incontinence or transfer needs were not evaluated, and fall care plans were not promptly or appropriately updated to address identified risks. One resident with diabetes, COPD, osteoarthritis, and a history of right fibula fractures was cognitively intact and occasionally incontinent of bladder, but had no toileting program and no assessment of incontinence as a fall risk factor. This resident had an unwitnessed fall in the bathroom while self-transferring from the toilet, resulting in facial bruising and swelling. The fall care plan was revised only to include re-education to call for assistance and placement of a “Call No Fall” sign, with no documented evaluation of urgency, frequency, or incontinence as contributors and no toileting-related interventions. Later, the same resident had an unwitnessed fall from bed resulting in a fractured right fibula; the fall scene investigation contained unclear handwritten notations, contradictory information about footwear, a blank root cause analysis section, and no documented assessment of bladder incontinence or toileting needs as potential contributors. The falls care plan was not revised after this second fall, and the resident’s bed was observed not in the lowest position despite documentation that this was an intervention. Another resident with diabetes, orthostatic hypotension, cirrhosis with ascites, compression fracture, osteopenia, and atrial flutter was cognitively intact and required extensive ADL assistance, with an order for a blood thinner. The ADL care plan listed all transfer types and assistance levels without individualization. Therapy evaluated this resident and recommended maximum assistance of two with a non-motorized sit-to-stand device and gait belt, but this recommendation was not added to the ADL care plan before a witnessed fall occurred during a pivot transfer with one-person assistance. Staff reported that the CNA worksheet, derived from the care plan, contained multiple and conflicting transfer instructions, and the care plan had not been updated with the therapy recommendation until two days after the fall. A cognitively intact hospice resident with spinal degeneration and Alzheimer’s disease had a falls care plan with generic interventions, including keeping the bed at an “appropriate height” without clarification. This resident had an unwitnessed fall from bed, stating they were trying to get to their son. The fall scene investigation documented impaired mentation and rolling out of bed as factors, but omitted key sections such as footwear, affect prior to the fall, recent medication changes, and environmental factors. The root cause was documented only as confusion, the interventions section was left blank, and there was no IDT root cause analysis form provided. The falls care plan was not revised until eight days later, when a fall mat was added, and later observation showed the bed at hip height with no fall mat in place. Another resident with a stroke, left-sided weakness, cognitive impairment, and dependence on staff for dressing and hygiene had a falls plan of care with only generic interventions and no individualized fall prevention measures. The resident care guide’s safety section contained no fall interventions, despite the resident being incontinent and requiring one-person assistance for transfers and ADLs. This resident experienced multiple unwitnessed falls in the facility, including falls from bed that resulted in hospital transfers. For at least one fall, the documented root cause was that the resident “wanted something to eat,” but there was no supporting documentation for this conclusion and no documented interventions or care plan revisions to prevent recurrence based on that or any other possible etiology. Across these cases, staff interviews revealed uncertainty about who was responsible for updating care plans after falls, with an LPN stating they had never updated a care plan and believed unit managers did so, and a unit manager acknowledging that root cause analyses had not been done for a period due to lack of unit managers. CNA worksheets used for daily care were generated from the care plans and, in at least one case, contained multiple, conflicting transfer instructions because the care plan itself was not individualized. These actions and inactions resulted in falls not being thoroughly assessed, root causes not being clearly identified or documented, and fall care plans not being promptly or adequately revised to address resident-specific risks such as incontinence, transfer method, bed height, and use of fall mats.
Failure to Comprehensively Assess Wounds and Post-Fall Status for Multiple Residents
Penalty
Summary
The deficiency involves multiple failures to comprehensively assess residents and provide treatment and care in accordance with professional standards and facility policy. One resident with diarrhea related to IV antibiotics reported red, raw skin on the buttocks; nursing documentation later identified maceration in the gluteal fold but did not include measurements or tissue descriptors, and there was no documentation that a physician or NP was notified of this new skin breakdown. An antifungal powder was documented as being applied without a corresponding provider order, and the medicated powder—brought from a prior hospitalization—was being applied by a CNA rather than a licensed nurse. Subsequent skin documentation referenced “existing wounds” without specifying which wounds or describing them. Another resident was admitted with cellulitis of the right lower limb, diabetes, diabetic foot ulcers, and chronic non‑pressure ulcers. The record showed multiple documented wounds on admission, but there was no assessment or descriptive documentation of the right lower leg cellulitis itself, despite progress notes stating the cellulitis was being monitored. A treatment order to cleanse with normal saline or wound cleanser and apply betadine daily did not specify the anatomical location where the treatment was to be applied. The wound nurse later stated that non‑pressure wounds such as cellulitis were expected to be assessed and documented by floor nurses or the Unit Manager, and that she had noticed and changed the nonspecific order only after her first wound assessment. A third resident, cognitively intact and on Xarelto for atrial flutter, experienced an unwitnessed fall from bed, landing face down with the face resting on the metal base of an overbed table. Staff moved the table, rolled the resident, placed the resident on a mechanical lift sling, and transferred the resident to bed before contacting the NP. The resident had abrasions to the forehead, nose, and knee, a blood pressure of 86/57 with a pulse of 98, and altered mental status compared to prior documentation that the resident was alert and able to make needs known. EMS documentation indicated the resident was found in bed, was only oriented to person, had a weak pulse, and that the fall had occurred approximately 30 minutes before EMS arrival. Staff called a private ambulance service rather than 911, and the NP reported not being given any vital signs when notified of the fall. Another resident with Alzheimer’s disease and on hospice had an unwitnessed fall, was found on the floor, and reported back pain rated 10/10. The facility’s neuro assessment flow sheet and the DCO’s interview confirmed that neurological checks after a fall were to be completed every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for the next 2 hours, every 2 hours for the next 8 hours, every 4 hours for the next 12 hours, and then every shift for 48 hours. However, neurological assessments for this resident were only documented at six time points over approximately three hours, with gaps that did not follow the required frequency and no further neuro checks recorded after 1:20 PM. A fifth resident developed a new skin wound that was not comprehensively assessed for etiology or documented with appropriate interventions to promote healing. Although an NP ordered a wound consult on the same day the wound was identified, the consult was not completed. This resident also had an unwitnessed fall while on blood‑thinning medication and was unable to communicate whether the head was struck; despite this, a thorough neurological assessment was not completed post‑fall, contrary to the facility’s falls policy and neuro‑check protocol. Collectively, these events show repeated failures to perform complete assessments, obtain and follow appropriate treatment orders, and adhere to established neuro‑assessment and falls procedures for residents with new wounds, cellulitis, and unwitnessed falls, including those on anticoagulants and with head injuries.
Failure to Administer Medications Timely and as Ordered for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders and facility policy, including timeliness standards, for multiple residents. One resident with generalized anxiety disorder, severe cognitive impairment (BIMS score of 5), anxiety, and depression had a scheduled order for hydroxyzine 10 mg three times daily beginning mid-September. The MAR showed numerous instances where the hydroxyzine doses were administered outside the facility’s stated 1-hour before/after window, including morning, noon, and afternoon doses given significantly late on multiple days. The same resident’s hydroxyzine was also discontinued on one date and not restarted until two days later, resulting in missed doses, and when restarted with a new three-times-daily schedule, there were additional late administrations and at least one dose left blank, indicating it was not administered. The same resident’s hydroxyzine order was changed by a nurse practitioner from scheduled to PRN, and a subsequent progress note documented that an LPN contacted the practitioner to clarify the order after a family member reported what medication the resident was supposed to be receiving. At that time, the LPN noted there was no active order in the record, and a verbal order was given to restart the hydroxyzine. The facility’s MARs for September and October continued to show repeated late administrations of the hydroxyzine outside the scheduled time frames, including multiple morning doses given more than an hour after the scheduled time and some evening doses given early or late. The unit manager later stated she did not know who reviews provider assessments after visits, was unaware of who uploads them into the charts, and acknowledged that no one was currently reviewing them. Additional deficiencies were identified for other residents. One nurse administered multiple 8:00 AM medications, including atorvastatin, vitamin D3, sertraline, acetaminophen, propranolol, potassium ER, and apixaban, at 11:01 AM, two hours past the allowable window, and reported being pulled to other units to administer IV medications, with other residents’ 8:00 AM medications still pending. Another nurse administered 7:00 AM medications, including tramadol and omeprazole, after the allowed time window. A resident receiving IV cefepime 2 g every eight hours for a catheter-associated UTI had three initial doses not given because the medication had not arrived from the pharmacy, one dose documented as administered five and a half hours early, and several later doses not signed out at all. The DON later stated that a night-shift RN had come in early to hang IV medications and thought they had been signed out, but the MAR still lacked signatures for those doses when re-reviewed. The facility’s written policy required medications to be administered per orders within a 60-minute before/after window, which was not followed in these instances.
Failure to Report and Adequately Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report and thoroughly investigate alleged abuse and an injury of unknown origin, and to report these incidents to the State Agency as required by facility policy. One incident occurred when a confused resident entered another resident’s room; the resident in the room told the other to leave, but the intruding resident grabbed the resident’s forearm, causing the resident to scream in fear and experience forearm pain. A nursing progress note documented this resident‑to‑resident incident and that staff intervened, separated the residents, and notified leadership. However, there was no corresponding facility‑reported incident or investigation provided for this event, and the current NHA, who was not employed at the time, was unable to locate any prior investigation related to the incident. A second deficiency relates to an abrasion to the head identified as an injury of unknown origin for the same resident who had entered the other resident’s room. The facility produced an investigation document noting a skin abrasion and marks of unknown origin, with references to fall protocol review, staff statements, skin assessment, notifications, and neuro checks, but the factual discoveries section was left blank. The CNA and LPN who first identified and documented the injury on a shower sheet and in a progress note were not interviewed as part of the investigation. The DON acknowledged not knowing the source of the injury and could not explain why the investigation began three days after the injury was found, despite the facility’s abuse policy requiring immediate reporting and investigation of alleged abuse and injuries of unknown origin, including notification of the State Agency.
Failure to Timely and Thoroughly Investigate Abuse Allegation and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into an alleged resident-to-resident abuse incident and an injury of unknown origin. One resident reported that another confused resident entered the room, was told to leave, then grabbed the resident’s forearm, causing the resident to scream in fear and experience forearm pain. This event was documented in a nursing progress note as occurring during the evening shift, with staff intervening, separating the residents, and notifying leadership. However, when surveyors requested the investigation related to this resident-to-resident altercation, the current Nursing Home Administrator was unable to locate any investigation, and the DON stated that the former administrator would have handled it. No Facility Reported Incident investigation or related investigative documentation was provided for this event, despite facility policy requiring assignment of an investigation, interviews with staff on all shifts who had contact with the resident, and review of events leading up to the alleged incident. The facility also failed to promptly and thoroughly investigate an injury of unknown origin involving the same confused resident who was later found to have a skin tear/abrasion to the head during a skin check. The injury was identified and documented in the resident’s record, but the investigation was not initiated until three days later. The written investigation for the head abrasion stated that fall protocol was reviewed, staff statements were collected, a skin assessment was completed, and appropriate parties were notified, but the factual discoveries section was left blank. Surveyors noted that the CNA and LPN who first identified and documented the injury on the shower sheet and in the progress note were not interviewed, and the DON could not explain the source of the injury. The NHA stated that such a head injury would be considered an injury of unknown origin and that the expectation was for immediate initiation of an investigation, including review of history, resident and staff interviews, and review of interventions, which did not occur as required by facility policy.
High Medication Error Rate Due to Late Administration and Improper Alteration of ER Tablet
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent, resulting in a calculated error rate of 30 percent (9 errors out of 30 opportunities) during a medication pass observation. Facility policy titled "Administering Medications" dated 12/2025 required medications to be administered in accordance with orders and within a 60-minute window before and after the scheduled time. During observation on the morning of 1/21/2026, a registered nurse administered tramadol 50 mg and omeprazole 40 mg to one resident at 8:27 AM, although these medications were scheduled for 7:00 AM, placing them outside the allowable administration time frame. Later that morning, another registered nurse was observed preparing and administering multiple medications to a second resident, including atorvastatin 20 mg, Vitamin D3 200u, sertraline 50 mg, Tylenol 1000 mg, propranolol 60 mg, potassium ER 20 mEq, and Eliquis 5 mg. These medications were scheduled for 8:00 AM but were administered at 10:55 AM, again outside the facility’s defined time window. During this same pass, the nurse broke the potassium ER 20 mEq tablet in half, despite it being an extended-release formulation that is not to be broken or crushed due to its coating. The nurse reported being pulled to another unit to administer IV medications, which contributed to being behind schedule with medication administration on the unit. These observed late administrations and the improper alteration of an extended-release medication comprised the identified medication errors.
Failure to Maintain Accurate and Complete Daily Nurse Staffing Postings
Penalty
Summary
The deficiency involves the facility’s failure to ensure that daily nurse staffing postings were consistently displayed and accurately reflected actual staffing. Review of staffing schedules and required staff postings from 12/1/2025 through 1/20/2026 showed that 7 of 51 daily staff postings could not be located for specific dates, meaning the required information was not available on those days. Additionally, for the days where postings were available, the surveyor identified discrepancies between the posted staffing and the actual staffing schedules on two dates, specifically for the NOC shift. On those two dates, the NOC shift staff postings listed 4 CNAs, while the staffing schedules showed only 3 CNAs actually scheduled to work. During an interview, the Clinical Coordinator stated they were responsible for updating the staff postings to reflect the actual staff who worked the prior NOC shift and acknowledged that the postings for those dates should have been updated to show only 3 CNAs. The Clinical Coordinator was also unable to locate the missing staff postings and stated they should have been available. These issues affected the accuracy and availability of posted information about licensed staff directly responsible for resident care on the NOC shift for all 53 residents in the facility.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to provide evidence that an initial report of an abuse allegation was submitted to the State Survey Agency (SA) within the required two-hour timeframe for one of two residents reviewed for abuse. According to the facility's policy, all alleged violations involving abuse or serious bodily harm must be reported immediately, but not later than two hours after discovery. In this case, a resident alleged that a Certified Nurse Aide (CNA) refused to assist her to bed and was mean to her. The facility's documentation included a printed Misconduct Incident Report with the incident details, but the report was marked as a draft, and critical sections such as "Report Submitted BY" and "Report Submitted Date" were left blank. There was no documentation to confirm the actual date and time the report was submitted to the SA. During interviews, the Administrator referenced the Incident ID on the report as evidence of submission, but the absence of a submission date and time meant there was no verifiable proof that the abuse allegation was reported within the required two-hour window. The lack of proper documentation and timely reporting had the potential to delay corrective measures and appropriate responses to the abuse allegation, as required by facility policy and regulatory standards.
Incomplete Medical Record Due to Loss of Access to Contracted Provider Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who had a diabetic foot ulcer and was being followed by a contracted wound care provider. The resident was admitted with multiple diagnoses, including a right diabetic foot ulcer, and was cognitively intact during their stay. For four weeks, the resident's wound was assessed and treated by Wound MD-C, but after the facility changed its contract to a new wound care provider, it lost access to Wound MD-C's documentation. When the surveyor requested all wound assessments, the facility was only able to provide its own staff assessments and those from the new provider, Wound MD-D, but not the assessments from Wound MD-C. The Nursing Home Administrator confirmed that the facility no longer had access to Wound MD-C's records after the contract ended, resulting in an incomplete medical record for the resident.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure the safety of two residents, R1 and R2, from accidents and hazards. R1, who was admitted with diagnoses including Parkinson's Disease, Dementia, and unsteadiness on feet, experienced three falls during their stay. The facility did not complete fall risk assessments after each fall, as required by their policy, and did not implement appropriate interventions. Despite R1's severe cognitive impairment, the intervention of reminding R1 to ask for assistance was deemed inappropriate by the Director of Quality Assurance. R2, who was dependent on staff for transfers and had severe cognitive impairment, was involved in an incident where a Hoyer lift struck their lip during a transfer. The incident was not reported to the facility by the staff involved, and no immediate interventions were implemented to prevent future occurrences. The facility's Director of Nursing was unaware of the incident until informed by the surveyor, and the physician was only notified several days later. The surveyor noted that the facility's failure to conduct fall risk assessments for R1 and the lack of reporting and intervention following R2's incident were significant deficiencies. These actions and inactions contributed to the facility's inability to adequately supervise and protect residents from accidents and hazards, as required by their policies and procedures.
Inaccurate Medication Administration Records for a Resident
Penalty
Summary
The facility failed to ensure that medication administration records were complete and accurate for a resident, identified as R2, who was reviewed for medication administration. R2, who was admitted with diagnoses including Alzheimer's Disease, chronic pain, and dementia, had discrepancies in the documentation of their prescribed narcotic pain medication, Morphine. The Medication Administration Record (MAR) indicated that R2 received the medication twice in November 2024, while the facility's controlled drug log showed it was signed out six times. Further review revealed that the actual administration of Morphine was documented seven times, with multiple doses on some days not reflected in the regular MAR. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed inconsistencies in the documentation process. The LPN explained the procedure for counting narcotic medications, while the DON acknowledged that nurses sometimes entered medication administrations late, leading to discrepancies between the MAR and the narcotic medication logs. The surveyor noted that the facility did not ensure that R2's controlled medication was documented at the time of administration, resulting in inaccurate medication records.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for a resident identified as R307. R307, who was admitted with chronic peripheral venous insufficiency, lymphedema, and other conditions, developed a deep tissue injury on the left heel on 9/26/2023. However, the care plan was not revised until 9/29/2023. Subsequently, on 9/30/2023, R307 developed a suspected deep tissue injury on the right heel, but a comprehensive assessment was not completed until 10/3/2023, and the care plan was not updated accordingly. The facility's policy on pressure injury assessment and treatment was not followed, as evidenced by the lack of timely care plan revisions and comprehensive assessments. The policy requires immediate assessment and care plan updates when new skin concerns are observed, but these actions were delayed for R307. The resident's left heel injury worsened to an unstageable pressure ulcer by 10/3/2023, indicating a failure to implement effective pressure-relieving interventions and offloading techniques as recommended by the wound care specialist. Interviews with facility staff revealed gaps in communication and documentation. The Registered Nurse Unit Manager acknowledged that assessments and care plan updates should have been completed promptly, but no documentation was found for the right heel injury assessment. Additionally, there was no record of the resident refusing treatment or being informed of the risks and benefits of treatment refusal, as required by the facility's policy. These deficiencies highlight a lack of adherence to professional standards of practice in pressure ulcer care and prevention.
Dishwasher Malfunction and Maintenance Delays
Penalty
Summary
The facility failed to maintain proper working order of essential equipment, specifically two of the three dishwashing machines located in the unit kitchens. Observations revealed that these machines were leaking water onto the floor, creating a potential hazard. Additionally, one of the dishwashers did not have a functioning temperature display, which is necessary to ensure the machine reaches the required water temperature for effective sanitation. The Dietary Manager acknowledged the issues, stating that the leaking started recently and a maintenance request had been submitted. However, the temperature display issue had been ongoing for a week, and the staff relied on a disk simulator to verify the temperature, which was not demonstrated to the surveyor at the time. Further investigation showed that the Director of Facilities was only verbally informed about the leaking issue the night before or the morning of the survey. The dishwashing machines are serviced by a contracted company, and a request for service had not been formally submitted until the surveyor's inquiry. The Director of Facilities confirmed that they were waiting for a part to arrive before the contracted company could address the issue, with a service request confirmation dated two days after the initial observation. These deficiencies potentially affected all 24 residents on the two units where the dishwashers were located.
Missing DNR Forms in Resident Records
Penalty
Summary
The facility failed to ensure that advanced directives, specifically Do Not Resuscitate (DNR) forms, were present in the medical records of two residents, R6 and R19, as required by their policy. R6, who has a range of medical conditions including heart failure and dementia, was admitted with a moderately impaired cognitive status and an activated power of attorney for medical decisions. Upon review, the surveyor found that R6's DNR form was missing from the medical record, and the facility staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), were unable to locate it. They acknowledged the absence and were in the process of obtaining a new signed form. Similarly, R19, who is cognitively intact and has an activated power of attorney, also did not have a DNR form in their medical record upon review. Despite the facility's policy requiring the DNR form to be signed and placed in the resident's medical record upon admission, the form was not found. The NHA and DON were again unable to explain the absence of the form and were working to rectify the situation. The surveyor noted these deficiencies and shared concerns with the facility's administration.
Failure to Ensure Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at the time of their choosing. The deficiency involved a resident with severe cognitive deficits and an activated Power of Attorney for Health Care. The facility restricted the resident's family member to supervised visitation following an incident where the family member allegedly verbally and physically abused the resident. However, the facility did not develop strategies to ensure safe and enjoyable visits, nor did it provide supervision for weekend visits, effectively limiting the family member's access to the resident. The facility's administration did not meet with the family member to discuss the imposed visitation arrangements, and there was no documentation of any plan to change the visitation restrictions. The social worker did not document interactions with the resident regarding the restricted visitation or assess the potential impact on the resident. Additionally, the family member was not informed of the requirements for supervised visitation and was turned away when attempting to visit without an appointment. The facility's policy stated 24-hour access for visitors, which was not upheld in this case.
Neglect in Resident Transfer Using Hoyer Lift
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a Hoyer lift transfer. The resident, who has a history of cerebral infarction resulting in left side hemiplegia, dysphagia, and other conditions, was transferred by a single staff member using a Hoyer lift, contrary to the care plan that required two staff members for such transfers. This resulted in a bruise on the resident's right forearm. The facility's policy on mechanical lifts mandates the use of such equipment according to current standards and guidelines, which were not followed in this instance. The incident was documented in the facility's progress notes, and the resident was noted to have a bruise that increased in size over time. The resident was on medications that increased the risk of bleeding, which may have contributed to the severity of the bruise. During interviews, the resident could not recall the specifics of the transfer or how the bruise occurred, and the staff member involved was no longer employed at the facility. The facility's investigation concluded that the bruise was a result of the improper transfer by a single staff member, which was a deviation from the resident's care plan.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to report three allegations of abuse and neglect involving a resident, identified as R36, within the required timeframe to the Nursing Home Administrator (NHA) and the State Agency. The incidents included verbal and physical abuse by the resident's family member, as well as an allegation of neglect. The verbal abuse incident was observed on August 11, 2024, but was not reported to the NHA until August 15, 2024, and subsequently to the State Agency on August 16, 2024. The physical abuse, which occurred on August 10 and 11, 2024, was not reported to the NHA until August 17, 2024, and was only reported to the State Agency on September 18, 2024, during the survey. The facility's policy on abuse prevention requires immediate reporting of such incidents, but this was not adhered to. Staff members, including a Registered Nurse (RN) and Certified Nursing Assistants (CNAs), witnessed the abuse but failed to report it promptly. The RN heard the family member verbally abusing the resident and was informed of physical contact by CNAs, yet did not report these observations immediately. Similarly, the CNAs who witnessed the abuse did not inform the facility administration until days later, during an investigation of the verbal abuse allegation. Additionally, an allegation of neglect was reported to an RN on June 2, 2024, regarding the resident being left in a wheelchair for 40 hours continuously. This allegation was not reported to the NHA or the State Agency, as the RN dismissed it as implausible. The facility's policy mandates reporting neglect within specified timeframes, but this was not followed. The failure to report these incidents promptly and in accordance with policy was identified during the survey, highlighting deficiencies in the facility's handling of abuse and neglect allegations.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into three allegations of abuse and neglect involving a resident, identified as R36. The first incident involved an allegation of verbal abuse by R36's daughter, which was reported to have occurred on August 11, 2024. Despite being informed of the incident, the facility's investigation was incomplete as it did not involve a comprehensive discussion with the family to understand the context of the alleged abuse, nor did it address the family dynamics or the resident's cognitive impairments. Additionally, the facility did not adequately communicate the reasons for implementing supervised visits with the family. The second incident involved an allegation of physical abuse by R36's daughter, which emerged during the investigation of the verbal abuse incident. The facility administration was made aware of these allegations on August 17, 2024, but failed to initiate an investigation until September 17, 2024. This delay in response indicates a lack of adherence to the facility's policy on timely investigation and reporting of abuse allegations. The third incident involved an allegation of neglect, where it was claimed that R36 was left in a wheelchair for 40 continuous hours. This allegation was documented by RN-G on June 2, 2024, but was not reported to the Nursing Home Administrator or the Director of Nursing for investigation. RN-G dismissed the claim as implausible and did not document conversations with other staff regarding the incident. This oversight resulted in a failure to investigate a potential neglect situation, as required by the facility's policies.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services to a resident, identified as R36, to help them achieve the highest possible quality of life. R36, who has severe cognitive deficits due to Alzheimer's Disease, was subjected to restricted visitation with a family member following an incident where the family member allegedly verbally and physically abused R36. The facility instituted supervised visitation by appointment only, but did not assess or monitor the impact of this decision on R36's well-being. Additionally, there was no documentation of meetings with R36's family or Power of Attorney for Healthcare to discuss future visitation arrangements. The facility's social worker did not document interactions with R36 regarding the visitation restrictions or assess the potential impact on R36's mental health. The care plan for R36 was not updated to reflect the changes in visitation, and the family member reported being uninformed about the requirements for supervised visits. The facility's policy on social services emphasizes maintaining contact with family members and identifying social and emotional needs, but these were not adhered to in R36's case. The deficiency was noted during a survey, and no additional information was provided by the facility to explain the lack of assessment and monitoring of R36's mental well-being after the visitation restrictions were implemented.
Failure to Promptly Resolve Resident Grievances
Penalty
Summary
The facility did not make a prompt effort to resolve grievances for four residents. One resident voiced concerns about not being dressed or getting out of bed until the second shift and not receiving a shower. The facility did not follow up with the resident to ensure there were no further concerns and did not document the date the written decision was issued. Another resident had similar concerns about not being dressed until the second shift, and the facility failed to include a summary of findings or a conclusion in the grievance documentation. Additionally, the facility did not follow up with this resident to see if there were any further concerns and did not document the date a written decision was issued. A representative for another resident filed a grievance about the resident not receiving a shower, being soaked, and needing a new pad. The grievance documentation lacked a summary of findings or conclusions, confirmation of receipt, follow-up with the representative, and the date the written decision was issued. Similarly, a friend of another resident filed a grievance about the resident not receiving a shower, and the documentation did not include the date a written decision was issued. The facility's grievance policy requires documentation of the date the grievance was received, a summary of the grievance, steps taken to investigate, findings or conclusions, confirmation of the grievance, corrective actions, and the date the written decision was issued. The policy also mandates acknowledging the grievance within seven working days and issuing a final written decision within 30 days. The facility failed to adhere to these requirements, as evidenced by the incomplete and inconsistent documentation of the grievances reviewed by the surveyor.
Failure to Provide Consistent Showering Assistance
Penalty
Summary
The facility did not ensure that a resident received the required assistance with their activities of daily living (ADLs), specifically in relation to showering and bathing. The resident, who was admitted with diagnoses including Parkinson's Disease, status post left hip fracture, chronic kidney disease (CKD), and chronic lymphocytic leukemia (CLL), was assessed as requiring substantial assistance for showering. Despite this, the resident's care plan, which indicated a preference for showers and the need for extensive assistance with two-person staff support, was not consistently followed. Documentation revealed that the resident only received one shower during the weeks of 1/7/24 to 1/13/24 and 1/21/24 to 1/27/24, and no showers during the week of 1/28/24 to 2/3/24. Additionally, there were multiple instances where the daily charting by CNAs was either blank or indicated that the resident did not receive a shower or bath. Interviews with facility staff, including an LPN, CNA, DON, OTA, and RN Unit Manager, revealed a lack of recollection or awareness regarding the resident's showering schedule and needs. The CNA confirmed that they document when a shower is provided, but the records did not reflect consistent care. The DON and other staff members were unable to provide additional information or recall specific details about the resident's showering routine. This lack of documentation and follow-through on the resident's care plan led to the identified deficiency in providing necessary assistance with ADLs.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility did not ensure that a resident received needed care and services based on professional standards of practice. Specifically, the facility failed to obtain weekly weights for a resident (R2) who was at risk for weight loss and had a physician's order for weekly weights. This failure occurred over a period of eleven weeks, during which the resident's weight was not recorded as required by the physician's order. The facility's weight monitoring policy, last reviewed in January 2023, mandates weekly weights for the first four weeks and monthly thereafter, but this was not adhered to in R2's case. R2 was admitted with multiple diagnoses, including Hemiplegia following a stroke, Diabetes Mellitus Type II, Dysphagia, and Obesity. The resident's admission weight was 186 lbs, and by the last recorded weight, it had dropped to 131.6 lbs. Despite the significant weight loss, the facility did not document weekly weights on several specified dates. Interviews with the Certified Dietician Manager and the Director of Nursing confirmed that the physician's order for weekly weights should have been followed, but no additional information was provided to explain the lapses in weight monitoring.
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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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