Autumn Lake Healthcare At Greenfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 5790 S 27th St, Milwaukee, Wisconsin 53221
- CMS Provider Number
- 525504
- Inspections on file
- 34
- Latest survey
- December 13, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Greenfield during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of inappropriate sexual behavior was not effectively monitored or separated from another severely cognitively impaired resident, resulting in repeated incidents of sexual abuse. Staff failed to report prior incidents to administration, care plans were not updated in a timely manner, and not all caregivers were informed of the need for increased supervision or separation, leading to further abuse.
Two residents with cognitive impairments were involved in incidents of inappropriate touching, which were reported by a family member to staff but not escalated to facility leadership or the state agency as required. The facility did not investigate or implement interventions, and the required abuse reporting protocol was not followed.
A resident with COPD was found to have a nebulizer mask left uncovered on the bedside table when not in use, contrary to facility policy requiring respiratory equipment to be stored in a plastic bag. Both an LPN and the DON confirmed the mask should have been covered, and observations on multiple occasions documented the deficiency.
A resident with a documented fish allergy was served a meal containing fish, despite the allergy being noted in the medical record and on the tray card. The resident did not eat the fish but experienced itching and required medication for relief. Staff interviews confirmed the error and indicated that food allergies were not sufficiently highlighted to prevent such incidents.
A resident with prostate cancer and a femur fracture did not have complete documentation in the medical record regarding the administration of a prescribed cancer medication. An LPN marked the MAR to reference additional details in the Progress Notes but did not document the administration in the notes, despite later recalling that the medication was given after being located with the help of a family member. The DON confirmed that proper documentation was required according to facility policy.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with intact cognition reported missing money from her purse, and although the Social Services Director assisted in searching and taking statements, law enforcement was not notified as required by facility policy. The Nursing Home Administrator confirmed that such incidents should be reported to police, but this did not occur in this case.
A resident with a history of depression and anxiety reported mistreatment by a CNA, including refusal of care and interference with the resident's ability to call for help. Although the incident was reported to an LPN and care was reassigned, the LPN did not notify facility leadership until the end of the shift, allowing the CNA to continue working in resident care. This delay in reporting and investigation was not in accordance with facility policy and resulted in a failure to immediately protect the resident.
A resident with mental health diagnoses had a care plan intervention to limit new staff assignments, but this was not communicated to CNA staff through care cards or other means. As a result, CNAs were unaware of the intervention and selected their own assignments, leading to an incident where the resident's psychosocial needs were not met during care by unfamiliar staff.
A resident with significant medical conditions was admitted with a Stage 3 sacral pressure injury, but did not receive a comprehensive wound assessment or timely treatment for several days. Wound care orders were inconsistently documented and not always implemented, and weekly wound assessments contained staging errors. Staff failed to consistently follow the care plan for pressure injury prevention, including not offloading the resident's heels or applying pressure-relieving boots, and improper dressing application was observed.
Two residents experienced falls due to inadequate supervision and failure to implement required assistive devices and interventions. In both cases, staff did not thoroughly investigate the circumstances of the falls, failed to follow or communicate care plan requirements such as the use of gait belts, and did not ensure that individualized fall prevention measures were in place or documented. The facility's policies for fall risk management and investigation were not consistently followed.
A resident with diabetes and other medical conditions did not have consistent documentation of meal intake during their stay, despite requiring sliding scale insulin administration based on food consumption. The facility was unable to provide records for most meals, and the nursing home administrator confirmed that staff are expected to document all meal intakes but could not explain the missing documentation.
A resident with type 1 diabetes did not receive ordered sliding scale insulin or blood glucose checks at dinner and bedtime due to delays in transcribing and confirming insulin orders, as staff awaited pharmacy clarification and substitution of insulin types. This resulted in missed administration of both insulin and required monitoring.
A resident with multiple medical conditions experienced a delay in obtaining and processing a urine specimen for a UA and C&S after the initial sample was not received by the lab, requiring a second collection and resulting in a delayed diagnosis and treatment of a UTI. Facility staff and lab representatives confirmed the absence of documentation regarding the first specimen and the delay in results notification.
Staff did not follow infection control protocols for a resident with pressure injuries requiring enhanced barrier precautions. During high-contact care activities, staff failed to wear gowns and did not perform proper hand hygiene, and there was no EBP signage or PPE cart outside the room as required. Interviews revealed confusion about responsibilities and inconsistent adherence to infection prevention policies.
The facility did not ensure daily posting of nurse staffing data, including the date, census, and actual hours worked by RNs, LPNs, and CNAs, in a visible location. Staffing information was not updated or displayed on weekends, as the receptionist responsible for this task was only present on weekdays. This resulted in inaccurate and incomplete postings for three months, affecting access to staffing information for all residents, staff, and visitors.
The facility failed to adhere to professional standards for food storage and ice machine maintenance. Observations revealed improperly stored food items in the freezer and refrigerator, including opened and undated packages. The dry storage area contained unlabeled containers, and the ice machine was covered with a white substance and dust, indicating neglect in maintenance. The Dietary Manager and Maintenance staff were unaware of the cleaning schedule for the ice machine filter, which should be cleaned twice a month.
The facility failed to maintain up-to-date background checks for a CNA, MT, and Cook, as required by their abuse policy. The CNA and MT, who worked directly with residents, had outdated checks, posing a potential risk to resident safety. The lapse was attributed to the absence of a permanent HR employee since September.
A facility failed to accurately document a resident's CPR preference in their EMR, leading to a discrepancy between the signed CPR Preference form and the EMR. The resident's form indicated no CPR, but the EMR showed Full Code. Staff interviews revealed reliance on the EMR for code status, which was incorrect for this resident. The issue was acknowledged by the DON and corrected before the survey ended.
The facility failed to complete Quarterly MDS assessments on time for two residents. The assessments were signed as complete before all sections were finalized, indicating a lack of adherence to the required timeframe. Interviews revealed that the MDS RN worked remotely and signed off prematurely, while the MDS LPN was new to the process. The assessments were admitted to be late, with no further explanation provided.
Two residents' Quarterly MDS assessments were not transmitted to CMS within the required 7-day period after completion. The assessments, completed by an RN working remotely, were submitted late due to oversight. An LPN, new to the MDS process, confirmed the delay during a surveyor's review.
A resident with schizoaffective disorder was not accurately screened for mental disorders in the PASSAR Level I process, leading to the omission of a necessary Level II screening. The Admission Director acknowledged the error, noting that schizophrenia should have been listed, which would have triggered further evaluation. The oversight was identified during a survey, and the Nursing Home Administrator and DON were informed.
The facility failed to develop comprehensive care plans for two residents, one with a foley catheter and another with COPD receiving oxygen and diuretic therapy. The catheter care plan was not implemented upon the resident's return from the hospital, and the other resident's care plan did not address their oxygen and diuretic therapies. The DON acknowledged these oversights.
A resident with Multiple Sclerosis and limited range of motion did not receive the prescribed passive range of motion (PROM) exercises twice daily, as facility staff failed to implement the program. Despite being discharged from active therapy, the resident's care plan required PROM to prevent further contractures. Interviews revealed that staff were not adequately trained or informed about the program, leading to inconsistent care and the resident's decline.
A resident at the facility, assessed as a high fall risk, did not have an adequate care plan developed or updated following a fall. Despite the facility's policy requiring comprehensive care plans, the resident's plan was not initiated or revised in a timely manner to include necessary fall prevention interventions. The Director of Nursing could not explain the oversight, and the care plan was only updated after surveyor intervention.
A hospice resident with severe pain was not administered scheduled Morphine as ordered, due to staff holding the medication when the resident was sleeping, despite no physician instructions to do so. The facility's lack of documentation and communication among staff led to the resident not receiving appropriate pain management, contrary to the care plan and professional standards.
A resident with multiple diagnoses, including dementia and diabetes, did not have a medication dose adjustment acted upon by the facility. A Consultant Pharmacist recommended reducing the dose of pantoprazole, which was signed by a Nurse Practitioner, but the order was not updated in the electronic medical record. The interim Assistant DON was responsible for updating orders but did not make the necessary change.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on olanzapine, prescribed for sundowning with dementia. Despite a pharmacy recommendation for a GDR, an unknown NP indicated it was unnecessary due to a psychiatric disorder, which was not supported by the resident's medical record. The resident exhibited no significant behaviors in November 2024, and a psychiatric NP noted normal mood and affect. The NHA was unaware of the NP's identity and acknowledged the need to investigate the lack of a GDR attempt.
A resident with multiple health issues and a moderate fall risk was observed to have only one fall mat in their room, despite their care plan requiring two. The care plan had not been updated since its initiation, and the discrepancy was confirmed by an LPN who was unfamiliar with the electronic charting system. The issue was reported to the DON, but no further action was noted.
Two residents in an LTC facility received inadequate pressure ulcer care. One resident's Stage 3 pressure injury was not comprehensively assessed upon admission, with inconsistent documentation of skin condition. Another resident, with a history of pressure injuries, was observed without required heel boots, contrary to their care plan. Staff interviews revealed unclear roles and inadequate documentation practices, contributing to the deficiencies.
A resident readmitted with a Foley catheter did not have physician orders for its care, leading to a deficiency in treatment. The facility's process for obtaining and implementing readmission orders was inadequate, as the hospital discharge summary lacked specific catheter care instructions. Staff interviews revealed reliance on incomplete documentation and a lack of clear communication regarding the resident's care needs.
A resident with a history of pressure injuries developed three new Stage 3 pressure injuries due to the facility's failure to revise the care plan with specific interventions for repositioning and incontinence care. The resident, who required substantial assistance and was at risk for pressure injuries, was often left in the same position for extended periods. Additionally, there were lapses in communication and documentation regarding the resident's condition, contributing to inadequate pressure ulcer care.
A resident with a significant decline in condition was readmitted to a facility without an updated care plan or CNA Kardex, leading to inadequate supervision and a fall resulting in injury. Despite requiring maximal assistance with ADLs and being at moderate risk for falls, the facility failed to revise care plans based on hospital recommendations, highlighting a lack of communication and documentation among staff.
A resident with severe cognitive impairment was observed self-administering Medihoney for wound care without an assessment by the interdisciplinary team. The facility's policy requires such an assessment to ensure safety, but no documentation was found in the resident's medical record. The RN/UM confirmed that the resident had not been taught to self-administer treatments, as she was not supposed to do so.
The facility failed to resolve grievances for two residents, including a missing CPAP machine and care concerns. Despite multiple notifications, grievances were not documented or investigated, violating the facility's policy and residents' rights.
The facility failed to thoroughly investigate allegations of abuse and protect residents during investigations. In one case, a resident-to-resident altercation was not fully investigated as other residents were not interviewed. In another case, a CNA accused of verbal abuse was allowed to continue working with residents during the investigation, contrary to facility policy. The facility's policies on abuse prevention and investigation were not fully adhered to, contributing to the deficiency.
The facility failed to provide care according to professional standards and resident care plans. A resident with severe cognitive impairment was found self-administering wound care due to delays, contrary to physician orders. Another resident was given a wander guard without a proper assessment and lacked a smoking assessment despite being identified as a smoker. These actions indicate non-compliance with facility policies for resident safety and care.
A resident with dementia was prescribed Donepezil and Olanzapine for behavior management, but the facility failed to document behavior monitoring as required. Despite the care plan's directive for monitoring, the Director of Nursing confirmed that this was not done since the resident's admission, raising concerns about the medication regimen's appropriateness.
A facility failed to maintain an effective infection prevention and control program, as staff did not adhere to enhanced barrier precautions (EBP) for a resident with Stage 3 pressure injuries. Observations revealed the absence of EBP signage and PPE carts, and staff did not wear gowns or perform proper hand hygiene during incontinence care. Interviews with facility staff indicated a lack of awareness and communication regarding EBP requirements.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Reporting and Care Planning
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident with a history of inappropriate sexual behavior. One resident, who had diagnoses of metabolic encephalopathy and dementia and was moderately cognitively impaired, had previously attempted to kiss another resident and was reported to have tried to fondle the breasts of a severely cognitively impaired resident. Despite these incidents, the facility did not implement effective preventive measures or update the resident's care plan to address these behaviors until after a subsequent incident occurred. On a later occasion, staff witnessed the same resident with his hand down the pants of the cognitively impaired resident in a common area. Although staff immediately intervened and separated the residents, prior reports of inappropriate behavior had not been communicated to administration or properly documented. Interviews revealed that some staff were aware of previous incidents but did not report them to administration or initiate an investigation, and other staff were unaware of the need to monitor or separate the residents. The care plan for the resident exhibiting inappropriate behavior was not updated to include interventions for these behaviors until after the most recent incident. The facility's failure to report, investigate, and implement preventive measures following initial incidents allowed further abuse to occur. There was a lack of communication among staff and administration regarding the resident's behaviors, and no safety risk evaluation was completed prior to the most recent incident. The facility did not revise the care plan for the victimized resident after the incidents, and not all caregivers were informed of the need for increased monitoring or separation of the residents involved.
Removal Plan
- Completed a root cause analysis to identify failure to report abuse to administration and prevent reoccurrence.
- Assessed each resident and established a care plan and supervision.
- Established systems to monitor and document frequency of behaviors.
- Completed assessments as indicated by psych services.
- Trained facility staff on practices and changes to systems.
- Established a system for auditing and monitoring along with QAPI.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the state agency, as required by policy. One resident with dementia and moderate cognitive impairment was documented in a psychiatric progress note for inappropriately attempting to kiss another resident, and staff were instructed to redirect him and keep him away from vulnerable patients. However, there was no care plan addressing sexual inappropriateness for this resident prior to a later date. Another resident, who was severely cognitively impaired and dependent on staff for mobility, was reported by a family member to have been touched inappropriately by the first resident. This information was relayed to a unit manager and a certified medication aide, but neither the social worker, DON, ADON, nor the administrator were made aware of the allegations or the incident documented in the psychiatric note. As a result, the facility did not investigate the incidents or implement interventions to prevent further occurrences. The lack of reporting and investigation allowed the inappropriate behavior to continue, as there was no documentation of actions taken to address the situation. The facility's policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities, but this protocol was not followed in these cases.
Failure to Maintain Cleanliness of Nebulizer Mask
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have a nebulizer mask left uncovered on the bedside table when not in use. The resident had a physician's order for Budesonide Inhalation Suspension to be administered twice daily for shortness of breath related to COPD. Observations on two separate occasions confirmed that the nebulizer mask was not stored in a plastic bag as required by facility policy. Interviews with an LPN and the Director of Nursing confirmed that the nebulizer mask should have been kept in a plastic bag when not in use, in accordance with the facility's policy on oxygen administration. The failure to properly store the nebulizer mask represented a lapse in maintaining the cleanliness of respiratory equipment for the resident.
Failure to Prevent Allergen Exposure in Resident Meal Service
Penalty
Summary
A deficiency occurred when a resident with a documented fish allergy was served a meal containing fish. The resident's electronic medical record included clear documentation of the fish allergy, and the allergy was also noted on the resident's tray card. Despite these precautions, the resident received a tray with fish during supper. The resident did not consume the fish but reported experiencing itching after having the fish in her room, which led to the administration of Benadryl and hydrocortisone ointment for relief. The resident was cognitively intact and communicated her allergy and reaction to staff. Interviews with staff revealed that the dietary aide responsible for serving the meal was made aware of the error and was sent home early that day. The Dietary Manager stated that staff were instructed to highlight food allergies to prevent similar incidents. The facility's policy on menus and nutrition required documentation of resident preferences but did not specifically address food allergies. The administrator confirmed the expectation that dietary staff should be attentive to resident allergies and avoid serving allergenic foods.
Incomplete Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident. The resident, who was admitted with a left femur fracture and prostate cancer with bone metastasis, had a physician's order for apalutamide, a hormone blocker used to treat prostate cancer. On a specific date, the Medication Administration Record (MAR) indicated with code 9 that additional details regarding the administration of apalutamide should be referenced in the Progress Notes. However, a review of the Nursing Progress Notes revealed there was no documentation about the administration of the medication on that date. During an interview, an LPN recalled being unable to initially locate the cancer medication, but after a family member identified its location in the medication cart, the LPN administered it to the resident. The LPN was unsure if she documented the administration in the nurses' notes, despite having marked code 9 on the MAR. The Director of Nursing confirmed that the nurse should have either documented the medication as given or provided an explanation in the nurses' notes. The facility's policy requires documentation of medication administration or refusal as per facility guidelines.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Timely Report Alleged Misappropriation to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's money to local law enforcement within the required timeframe. The incident involved a resident with diagnoses including major depressive disorder, anxiety disorder, transient cerebral ischemic attack, and a history of repeated falls, who was cognitively intact at the time of the event. The resident reported missing money from an envelope in her purse and stated that the Social Services Director (SSD) took statements and assisted in searching for the missing money, but the money was not found and law enforcement was not contacted. Interviews revealed that the SSD did not notify the police because the resident expressed a desire to call the police herself and did not want the SSD to do so. The Nursing Home Administrator (NHA) confirmed that the expectation for such allegations was to contact law enforcement, but was on vacation during the incident. The facility's policy requires reporting all alleged violations, including misappropriation, to the administrator, state agency, Adult Protective Services, and law enforcement when applicable. Despite this, the required notification to law enforcement was not made for this incident.
Failure to Immediately Report and Investigate Alleged Mistreatment
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate and respond appropriately to an allegation of mistreatment involving a resident. The resident, who had diagnoses including major depressive disorder, anxiety disorder, and a history of transient cerebral ischemic attack, reported an incident involving a Certified Nursing Assistant (CNA) during morning care. The resident, who was cognitively intact, alleged that after requesting to use the toilet, the CNA used vulgar language, refused the request, and unplugged the resident's phone when the resident attempted to call the office. The resident then called out for help until another CNA responded and provided care for the remainder of the shift. The facility's policy requires immediate investigation and protection of residents when allegations of abuse, neglect, or exploitation arise. However, after the incident, the CNA in question continued to work in resident care for the rest of the shift. The nurse on duty was informed of the allegation and reassigned the resident's care to another CNA, but did not report the incident to the Nursing Home Administrator (NHA) or Social Services Director (SSD) until the end of the shift. This delay in reporting resulted in the alleged staff member remaining in a position to provide resident care after the allegation was made. Interviews with staff confirmed that the incident was not reported to facility leadership in a timely manner, contrary to facility policy. The NHA and SSD both indicated that they were only made aware of the situation at the end of the shift, and the CNA was suspended only after leadership was informed. The investigation documentation and staff interviews corroborated that the required immediate response and reporting procedures were not followed, leading to a lapse in resident protection during the investigation period.
Failure to Implement Person-Centered Care Plan for Resident's Psychosocial Needs
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan to address a resident's mental and psychosocial needs as identified in their assessment. The resident, who had diagnoses including major depressive disorder, anxiety disorder, and a history of falls, had an intervention documented in their behavioral care plan to limit the assignment of new staff or to have established staff introduce new staff slowly. This intervention was intended to help set a positive tone and build trust with the resident. Despite being documented in the nurse's care plan, this intervention was not included on the CNA care plan or care card, which are the primary tools used by CNA staff to guide daily care. Multiple interviews with CNA staff revealed that they were unaware of the intervention, as it was not communicated to them through the care cards or posted in the resident's room. Staff also reported that CNAs typically select their own resident assignments and that there was no system in place to ensure that new or agency staff were limited in their assignment to this resident, as required by the care plan. The deficiency was further evidenced by an incident in which the resident experienced distress during care provided by a CNA unfamiliar to them, resulting in a negative interaction. The lack of communication and implementation of the care plan intervention meant that staff were not informed of the resident's specific needs, leading to the failure to provide care consistent with the resident's assessed mental and psychosocial requirements.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
A resident with multiple comorbidities, including sickle cell disease, chronic kidney disease, cerebral infarction, hypertension, diabetes mellitus, and spastic hemiplegia, was admitted to the facility with a Stage 3 sacral pressure injury. Upon admission, there was no comprehensive wound assessment or treatment initiated until four days later. Initial physician orders for wound care were either not started, not documented as completed, or not transferred onto the treatment administration record (TAR), resulting in a delay in necessary wound care interventions. Throughout the resident's stay, weekly wound assessments were not consistently accurate, with pressure injuries on the right and left buttocks being incorrectly staged as Stage 2 when documentation described granulation tissue, which is not present in Stage 2 wounds. Observations during the survey revealed that staff did not consistently follow the care plan interventions, such as applying bilateral heel boots or offloading the resident's heels. The resident was frequently observed in bed without pressure-relieving boots, and her heels were resting directly on the mattress or on pillows without being properly offloaded, contrary to the care plan and professional standards of practice. Additionally, wound care was not always performed according to best practices. During a treatment observation, the adhesive portion of a border gauze dressing was applied directly over an open pressure injury, which was later confirmed by the wound physician as inappropriate. Staff interviews indicated a lack of clarity regarding wound assessment, staging, and dressing selection. The facility did not provide an explanation for the delay in comprehensive assessment and treatment initiation, nor for the incorrect staging of wounds and failure to consistently offload the resident's heels as required.
Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Fall Interventions
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents, as evidenced by incidents involving two residents. In the first case, a resident with diagnoses including Guillain-Barre syndrome, anxiety disorder, hypertension, and morbid obesity, and assessed as having moderate cognitive impairment and being dependent for transfers and toileting, experienced a fall. The facility did not thoroughly investigate the circumstances of the fall, including whether prior fall interventions were in place. Staff statements did not clarify when the resident was last checked, changed, or offered the commode, despite the resident stating she fell while attempting to use the bathroom. Additionally, a CNA was observed transferring the resident without a gait belt, contrary to the resident's care plan, and was unaware that a gait belt was required for transfers. The CNA relied on a roster that did not specify the need for a gait belt, and the DON confirmed that staff are expected to use gait belts but could not confirm consistent practice or staff awareness of individual resident requirements. In the second case, another resident with multiple diagnoses, including sickle cell disease, chronic kidney disease, cerebral infarction, and spastic hemiplegia, fell while reaching for something from her wheelchair. The baseline care plan identified the resident as at risk for falls but did not include any specific interventions or approaches. The facility's investigation into the fall was incomplete, as the staff statement obtained was from a CNA not scheduled to work at the time of the incident, and there was no evidence that the CNAs who were present were interviewed. The care plan addressing fall risk was not developed until after the fall occurred, and the investigation did not clarify the circumstances leading up to the fall or whether appropriate interventions were in place at the time. Both incidents demonstrate a lack of thorough investigation and failure to ensure that care plans and interventions were communicated and implemented as required. Staff were either unaware of or did not follow the prescribed interventions, such as the use of gait belts during transfers, and documentation was insufficient to determine whether residents were adequately supervised or assisted to prevent accidents. The facility's policies required individualized interventions and thorough investigations, but these were not consistently followed in the cases reviewed.
Failure to Document Meal Intake for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including type 1 diabetes, right femur fracture, Parkinson's disease, and anxiety, maintained acceptable parameters of nutritional status. The resident was admitted and subsequently discharged to the hospital due to a change in condition. During the resident's stay, the facility did not consistently document meal intake, which was necessary for monitoring nutritional status and for the safe administration of sliding scale insulin as ordered by the physician. The only available documentation showed that the resident ate 75%-100% of one meal, with no records for subsequent meals during the remainder of the stay. Despite the resident requiring supervision for activities of daily living and being cognitively intact, there was no evidence in the electronic medical record of meal intake for most of the resident's stay. The facility's nursing home administrator confirmed that staff are expected to document all meal intakes but was unable to provide additional documentation or explain the lack of records. This lack of documentation meant the facility could not demonstrate that the resident's nutritional needs were being met or that insulin was administered safely in accordance with the resident's meal consumption.
Failure to Administer Ordered Insulin and Blood Glucose Checks Due to Delayed Order Transcription
Penalty
Summary
A resident with diagnoses including type 1 diabetes, right femur fracture, Parkinson's disease, and anxiety was admitted to the facility with physician orders for sliding scale Novolog insulin at all meals and bedtime, blood glucose checks at all meals and bedtime, and Lantus 30 units at bedtime. On the day of admission, the medication administration record (MAR) shows that the resident did not have a blood glucose check completed for the dinner meal and did not receive any insulin at that meal. At bedtime, although the blood glucose was checked and Lantus was administered, the ordered sliding scale Novolog insulin was not given, despite the MAR indicating it was required. Interviews with nursing staff revealed that the sliding scale insulin and blood glucose check orders were not transcribed into the MAR until later, with the Novolog sliding scale order entered in the evening and the blood glucose check order the following day. Staff indicated that there was a delay in confirming the insulin orders due to the pharmacy needing to substitute Humalog for Novolog, as only Humalog was available. This delay in order transcription and confirmation resulted in the resident not receiving the prescribed insulin and blood glucose monitoring as ordered on the day of admission.
Delay in Laboratory Testing and Notification for UTI
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a laboratory test was obtained and processed in a timely manner for one resident. The resident, who had diagnoses including acute cerebrovascular insufficiency, anxiety, depression, and alcohol use, was cognitively intact and required supervision for toileting. An order for a urinalysis (UA) and culture and sensitivity (C&S) was placed, and the urine specimen was initially collected as ordered. However, there was no documentation regarding what happened to the first specimen collected, and the laboratory did not receive it. As a result, a second urine sample had to be collected two days later, and the laboratory did not receive this specimen until the following day. The delay in obtaining and processing the laboratory test led to a delay in identifying a urinary tract infection (UTI) and initiating antibiotic treatment. Nursing notes indicated that the results were pending for several days, and the nurse practitioner was not updated with the results until the laboratory reported them. Interviews with facility staff and the laboratory confirmed that the initial specimen was not received, and there was no clear documentation explaining the delay or the need for a second collection.
Failure to Implement Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program for a resident requiring enhanced barrier precautions (EBP) due to pressure injuries. Multiple observations revealed that staff did not follow established protocols for hand hygiene and use of personal protective equipment (PPE) during high-contact care activities, such as incontinence care and wound treatment. Specifically, staff were observed not wearing gowns as required, and hand hygiene was not performed at appropriate times, such as after glove removal and between care tasks. The resident involved had significant medical conditions, including sickle cell disease, chronic kidney disease, cerebral infarction, hypertension, diabetes mellitus, and spastic hemiplegia, and was documented to have pressure injuries on the sacrum and right buttocks. The care plan and facility policy required EBP, including the use of gowns and gloves for high-contact care, signage on the resident's door, and the availability of PPE at the point of care. However, there was no EBP sign or PPE cart outside the resident's room during multiple observations, and staff were not consistently aware of or adhering to EBP requirements. Interviews with staff and the Director of Nursing confirmed lapses in protocol, including uncertainty about who was responsible for ensuring EBP signage and PPE availability, and acknowledgment of shortages in PPE carts. Staff also demonstrated inconsistent knowledge and practice regarding hand hygiene and PPE use, as evidenced by their actions during observed care episodes. The surveyor was unable to locate a physician order for EBP in the resident's records, further indicating gaps in the implementation of infection control measures.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data, including the date, resident census, and total actual hours worked by RNs, LPNs, and CNAs, was posted daily in a visible and accessible location. The nurse staffing posting was not updated or displayed on weekends, as the responsibility for updating the document fell solely on the receptionist, who only worked Monday through Friday. As a result, the staffing information was not accurately posted or maintained for the three months reviewed, and the postings did not reflect the actual number of staff present in the building on a daily basis. Interviews with the receptionist and the Nursing Home Administrator confirmed that the process for updating the nurse staffing hour document was not followed on weekends, and that new receptionists had not been educated on this responsibility. The surveyor's review of schedules and posted documents for January, February, and March revealed discrepancies and missing updates, affecting the ability of residents, staff, and visitors to access accurate staffing information. This deficiency had the potential to affect all 82 residents residing in the facility.
Deficient Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. In the kitchen's freezer, an unopened package of imitation crab meat, an opened bag of whipped topping, and three small containers of ice cream were found on the floor, contrary to the facility's policy that requires food to be stored at least six inches from the floor. Additionally, opened boxes of hamburger patties and hot dogs were not sealed or dated, violating the policy that mandates foods in the refrigerator to be covered, labeled, and dated. In the dry storage area, containers with red beans and pearled barley were not labeled or dated, further breaching the facility's storage guidelines. The ice machine outside the freezer door was covered with a dry, crusty white substance, and its filter was heavily dust-covered, indicating neglect in maintenance. The Dietary Manager admitted to not knowing the cleaning schedule for the ice machine filter, which should be cleaned twice a month according to the sign on the machine. The Maintenance staff also confirmed that the facility does not handle the cleaning or changing of the ice machine filter, which is contracted out. These observations were communicated to the Nursing Home Administrator, but no additional information was provided to explain why the facility did not adhere to professional standards for food service safety.
Failure to Maintain Up-to-Date Employee Background Checks
Penalty
Summary
The facility failed to implement its abuse policy and procedure by not ensuring that background checks were up to date for three employees, including a Certified Nursing Assistant (CNA), a Medication Technician (MT), and a Cook. The policy required background checks to be conducted every four years to screen for any history of abuse, neglect, exploitation, or misappropriation of resident property. However, the background checks for these employees had lapsed beyond the four-year requirement. Specifically, the CNA and MT, who worked directly with residents, had their last background checks completed over four years ago, and the Cook, who did not have direct resident contact, also had outdated background check information. The deficiency was identified during a survey when the Nursing Home Administrator (NHA) was unable to provide current background check documentation for these employees. The NHA acknowledged the oversight and indicated that the facility had been without a permanent Human Resources (HR) employee since September, which contributed to the lapse. The NHA had completed the necessary background checks after the surveyor's request, but this action was not timely, as it occurred only after the deficiency was identified. The lack of up-to-date background checks for employees who have direct contact with residents posed a potential risk to resident safety and well-being.
Discrepancy in Resident's CPR Preference Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive wishes were accurately reflected in their medical record. A resident, identified as R47, had a signed Cardiopulmonary Resuscitation (CPR) Preference form indicating they did not want CPR attempts. However, the electronic medical record (EMR) for R47 incorrectly documented the resident's code status as Full Code, which contradicted the resident's expressed wishes. This discrepancy was discovered during a surveyor's review of the resident's records. Interviews with facility staff revealed a breakdown in the process of updating and verifying the resident's code status in the EMR. The Licensed Practical Nurse (LPN) indicated that they would rely on the EMR to determine a resident's CPR preference, which would not have provided accurate information for R47. The Social Services Director and Admissions staff confirmed that the CPR Preference form is included in the admission packet and should be uploaded into the EMR. The Director of Nursing acknowledged the discrepancy and indicated that the facility would need to correct the code status in the EMR for R47. The surveyor informed the Nursing Home Administrator of the concern, and the discrepancy was reportedly fixed before the survey concluded.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents, R71 and R45. For R71, the Quarterly MDS assessment was dated with sections signed as completed on various dates in November 2024, but the assessment was signed in Section Z as being completed on November 12, 2024, which was before any sections were actually completed. Similarly, for R45, the Quarterly MDS assessment was dated with sections signed as completed in early December 2024, yet Section Z was signed as completed on November 13, 2024, prior to the completion of other sections. This discrepancy indicates that the assessments were not completed within the required timeframe, as the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). Interviews with facility staff revealed that the MDS RN responsible for signing off on the assessments was working remotely and had signed the assessments as complete before the other sections were finalized. The MDS LPN, who had recently started handling MDS assessments, was unable to provide a clear process for scheduling and completing assessments. The MDS RN admitted that the assessments for R71 and R45 were late and had been missed initially, leading to their late completion. The Nursing Home Administrator was informed of the late assessments, but no additional information was provided to explain why the facility failed to ensure timely completion of the Quarterly MDS assessments.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to transmit the Quarterly Minimum Data Set (MDS) assessments for two residents, R71 and R45, within the required 7-day period after completion. R71's assessment was completed on 11/12/2024, and R45's on 11/13/2024, but both were not submitted to the Centers for Medicare and Medicaid Services (CMS) until 12/10/2024. This delay was identified during a surveyor's review, which noted that the facility's policy required transmission within 14 days of completion, yet the assessments were still late. During an interview, MDS LPN-X, who had recently started handling MDS assessments, indicated that MDS RN-Y, who was responsible for the submissions, was working remotely and had forgotten to transmit the assessments. MDS RN-Y confirmed the oversight in a phone interview, acknowledging the late submission of the assessments. The Nursing Home Administrator was informed of the issue, but no additional information was provided to explain why the facility did not ensure timely transmission of the assessments.
Failure to Accurately Screen Resident for Mental Disorders in PASSAR Process
Penalty
Summary
The facility failed to accurately screen a resident for mental disorders as part of the Preadmission Screening and Resident Review (PASSAR) process. A resident was admitted with diagnoses including opioid dependence, delirium, schizoaffective disorder, heart failure, type 2 diabetes, and major depressive disorder. However, the PASSAR Level I screen completed for this resident did not identify any mental disorders, despite the presence of schizoaffective disorder, which should have triggered a Level II PASSAR. This oversight was attributed to the Business Office Manager who signed off on the Level I screen without noting the mental disorder. During an interview, the Admission Director acknowledged the error, stating that schizophrenia should have been listed as a mental illness on the PASSAR Level I screen, which would have necessitated a Level II screening. The Admission Director admitted to not having completed the initial PASSAR Level I screen for the resident but recognized the need to review and correct it once she assumed responsibility for the facility's PASSARs. The Nursing Home Administrator and Director of Nursing were informed of these findings, but no additional information was provided to the surveyor.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. One resident, who was readmitted to the facility with a foley catheter following a hospital stay, did not have a catheter care plan implemented upon their return. Despite having a physician order for a foley catheter due to retention, the care plan was not updated to include this intervention until several weeks later. The Director of Nursing confirmed the absence of an individual care plan for the catheter, acknowledging the oversight. Another resident with Chronic Obstructive Pulmonary Disease (COPD) and receiving oxygen therapy and diuretic medication also lacked a comprehensive care plan addressing these therapies. The resident's physician orders included continuous oxygen therapy and a diuretic for diuresis, yet these were not reflected in the care plan. The Director of Nursing indicated that while they typically do not start a diuretic care plan, they would expect to see one included eventually. The absence of these care plans was noted by the surveyor, highlighting a failure to address the resident's specific medical needs in their care plan.
Failure to Implement Range of Motion Program for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment to prevent further contractures and decreased range of motion in their upper and lower extremities. The resident, who was admitted with diagnoses including Multiple Sclerosis, Hemiparesis, Hemiplegia, Paraplegia, Quadriplegia, and contracture of the left hand, was supposed to receive a passive range of motion (PROM) program twice daily as ordered by the physical therapy department. However, the program was not consistently implemented by the facility staff, leading to the resident's decline in condition. Interviews with the resident and their family revealed that the facility staff did not perform the range of motion exercises as required, and the family had to provide additional support and equipment for the resident's care. The Director of Therapy confirmed that the resident was discharged from active therapy services and was set up with a passive range of motion program to be completed by facility staff. However, the staff did not have clear documentation or training on how to implement the program, and there was no evidence of the exercises being performed consistently. Further interviews with various staff members, including CNAs and the Nursing Home Administrator, highlighted a lack of communication and documentation regarding the resident's restorative program. The staff were unsure of where to find the program details or how to document the exercises, and the restorative aide, who was trained on the exercises, was not provided with the necessary materials to train other staff. As a result, the resident's care plan, which required passive range of motion exercises twice daily, was not followed, contributing to the resident's decline in range of motion and increased contractures.
Failure to Develop and Update Fall Prevention Care Plan
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as R335. Despite being assessed as a moderate risk for falls on one occasion and a high risk following a fall, the facility did not develop or update a comprehensive care plan to address these risks. The resident, who was readmitted to the facility with conditions including cellulitis, type 2 diabetes, and metabolic encephalopathy, experienced a fall on 9/28/2024. However, the care plan was not initiated or updated with interventions to prevent further falls, such as encouraging the resident to call for assistance when transferring and keeping a walker within close reach. The facility's policy requires that a comprehensive care plan be developed and maintained for each resident, incorporating identified problem areas and risk factors. Despite this, the care plan for R335 was not initiated or revised in a timely manner following the fall, and the Director of Nursing was unable to provide an explanation for this oversight. The surveyor noted that the care plan was eventually updated, but this occurred after the surveyor's intervention and was not part of the initial response to the resident's fall.
Failure to Administer Scheduled Pain Medication to Hospice Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a hospice resident, identified as R38, who was not administered his scheduled pain medication as ordered. R38, who was admitted to the facility on hospice care, had a medical history including Diastolic Congestive Heart Failure, Hypertension, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Myocardial Infarction. The resident's comprehensive assessment indicated frequent and severe pain, which affected his sleep and daily activities. Despite this, the facility did not administer the prescribed Morphine Sulfate Oral Solution every two hours as ordered, with documentation showing that the medication was held on several occasions without a valid reason. The report highlights that the facility's policy on pain management requires adherence to professional standards of practice and the resident's care plan. However, the facility staff failed to follow these guidelines, as evidenced by the Medication Administration Record (MAR) entries that indicated the medication was held because the resident was sleeping. The physician's order did not include instructions to hold the medication if the resident was asleep, yet the nurses assumed that the resident did not require pain management during these times. This assumption led to the resident going without pain medication for extended periods, as reported by the resident's Power of Attorney and confirmed by the hospice nurse. The deficiency was further compounded by the lack of documentation explaining why the medication was not administered and the absence of communication and education among the nursing staff regarding the proper administration of scheduled pain medication. The Director of Nursing acknowledged the issue but had not yet provided comprehensive education to all staff members. This oversight resulted in the resident not receiving the necessary pain management, contrary to the facility's policy and the resident's care plan.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident, identified as R47, who was admitted with multiple diagnoses including cerebral infarction, dementia, type 2 diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, and aphasia. The resident's Minimum Data Set indicated moderate cognitive impairment. A Consultant Pharmacist Recommendation to reduce the dose of pantoprazole to 20 mg per day was signed by the Nurse Practitioner but was not acted upon by the facility. As of December 11, 2024, the electronic medical record still reflected an order for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG, indicating no change in the dose had been made. The Director of Nursing (DON) was interviewed and stated that the interim Assistant DON was responsible for updating physician and medication orders in December, but was unsure why the update was not made. The Nursing Home Administrator was informed of the concern that the pharmacy recommendation, which was signed by the Nurse Practitioner, was not acted upon. The discrepancy was reportedly fixed before the surveyor exited the survey, but no additional information was provided regarding the resolution.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) for a resident on antipsychotic medication, specifically olanzapine, which was prescribed for sundowning associated with dementia. The resident, who has a diagnosis of dementia with psychotic disturbance and major depressive disorder, was noted to have severe cognitive impairment but did not exhibit physical or verbal aggression or rejection of care behaviors. Despite a pharmacy recommendation for a GDR attempt, an unknown nurse practitioner (NP) indicated that a GDR was not needed due to a psychiatric disorder, although the resident's medical record did not support the presence of such a diagnosis. The surveyor's findings highlighted that the resident's behaviors, such as delusional beliefs, verbal aggression, and tearfulness, were being monitored, but no behaviors were noted in November 2024. A psychiatric NP note from November 28, 2024, indicated the resident's mood was normal, with no delusions, paranoia, or hallucinations, and that olanzapine was used for dementia with moderate agitation. The Nursing Home Administrator (NHA) was unaware of the NP who signed off on the pharmacy recommendation and acknowledged the need to investigate the lack of a GDR attempt. As of December 12, 2024, no additional information was provided regarding the failure to attempt a GDR for the resident's antipsychotic medication.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, received adequate assistance devices to prevent accidents, specifically regarding the use of fall mats. R13's care plan, initiated on January 28, 2022, included the intervention of bilateral fall mats on the floor to mitigate the risk of falls. However, observations made by a surveyor on September 24, 2024, revealed that R13 had only one fall mat in the room, contrary to the care plan's requirement for two. This discrepancy was noted during two separate observations, one when R13 was in a Broda chair in the common area and another when R13 was lying in bed. R13 was admitted to the facility with multiple diagnoses, including osteoarthritis, malnutrition, anxiety, chronic kidney disease, and Alzheimer's disease, and was receiving hospice services. The resident was assessed as severely cognitively impaired and at moderate risk for falls. Despite these conditions, the care plan had not been revised since its initiation, and no falls had been documented for R13. The issue was brought to the attention of an LPN, who confirmed the care plan's requirement for bilateral fall mats but was unfamiliar with the electronic charting system, causing a delay in verifying the information. The Director of Nursing was also informed of the deficiency, but no further information was provided at that time.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, R14 and R13, leading to deficiencies in their treatment and prevention of further injuries. R14 was admitted with a Stage 3 pressure injury to the right buttock, which was not comprehensively assessed upon admission. The initial assessment lacked documentation of the tissue type and the number of open areas, and the comprehensive assessment was only completed four days later by a wound physician. Additionally, there were inconsistencies in the documentation of R14's skin condition, with records indicating both intact and non-intact skin on different days without detailed descriptions. R13, who was severely cognitively impaired and receiving hospice care, was observed without heel boots while sitting in a Broda chair, contrary to the care plan that required bilateral heel boots to prevent further pressure injuries. Despite having a history of pressure injuries and a current Stage 4 pressure injury to the sacrum, R13's care plan was not consistently followed, as staff were unaware of the requirement for heel boots. Observations revealed that R13's feet were pressed against the footboard of the chair, increasing the risk of further injury. Interviews with facility staff highlighted a lack of clarity and communication regarding the roles and responsibilities for wound assessments and care. The facility's documentation practices were also found to be inadequate, with important assessment details not being included in the medical record. This lack of comprehensive documentation and adherence to care plans contributed to the deficiencies observed in the care of residents with pressure injuries.
Deficiency in Foley Catheter Care for Readmitted Resident
Penalty
Summary
The facility failed to ensure that a resident with a Foley catheter received appropriate care and treatment, as there were no physician orders for the catheter's care upon the resident's readmission. The resident, who had a history of rhabdomyolysis, stage 3 kidney disease, type 2 diabetes, acute hypoxic respiratory failure, and urinary retention, was readmitted to the facility after a hospital stay. The hospital discharge summary did not include orders for the care and treatment of the newly placed Foley catheter, and the facility's care plan for the resident did not include specific interventions for catheter care. Interviews with facility staff revealed gaps in the process for obtaining and implementing readmission orders. The Unit Manager, who was new to the position, had not fully completed a readmission and relied on the Assistant Director of Nursing or Director of Nursing to handle the process. The CNA Kardex, which staff used to determine care needs, only mentioned providing Foley care every shift without specific instructions. It was only after the surveyor's inquiry that the Unit Manager updated the resident's physician orders to include Foley catheter care, indicating a lapse in the facility's protocol for ensuring comprehensive care upon readmission.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident with a history of pressure injuries received necessary treatment and services to prevent the development of new pressure injuries and to promote healing. The resident, who was admitted with multiple pressure injuries, developed three new Stage 3 pressure injuries on the coccyx and buttocks. Despite the development of these new injuries, the facility did not revise the resident's care plan to include specific interventions for repositioning frequency or incontinence care, which are critical for pressure injury prevention. The resident was assessed as being at risk for pressure injury development and was always incontinent of bowel and bladder, requiring substantial assistance for mobility and hygiene. However, the care plan lacked detailed instructions on repositioning and incontinence care, and the CNA kardex did not document these necessary interventions. Observations revealed that the resident was often left in the same position for extended periods, and staff did not consistently offer repositioning, which contributed to the development of new pressure injuries. Additionally, there were lapses in communication and documentation regarding the resident's condition. Nurses' notes indicated the presence of excoriation and open areas on the resident's buttocks, but there was no evidence of physician notification or orders for treatment. The facility's failure to update the care plan and ensure proper communication and documentation of the resident's condition contributed to the deficiency in providing adequate pressure ulcer care.
Failure to Update Care Plan and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and update care plans for a resident who experienced a significant change in condition. The resident, who was readmitted to the facility with a decline in cognition and activities of daily living (ADLs), was not provided with an updated care plan or CNA Kardex to reflect these changes. Despite being assessed as requiring maximal assistance with ADLs and having a moderate risk for falls, the care plan and Kardex were not revised to incorporate the recommendations from the hospital occupational therapist. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and was recently diagnosed with possible metastatic lung cancer, was admitted to hospice care. Upon readmission, the resident's cognitive status was impaired, and they required significant assistance with mobility and ADLs. However, the facility did not update the care plan or Kardex to reflect these needs, leading to inadequate supervision and a fall that resulted in a dislocated finger and laceration. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's change in condition. The Director of Nursing and Assistant Director of Nursing were unable to recall specific details about the resident's readmission and changes in condition. The CNA Kardex and care plan remained outdated, failing to provide staff with the necessary information to prevent accidents and ensure the resident's safety.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, was assessed by the interdisciplinary team to determine if it was clinically appropriate for her to self-administer medication. R5, who has diagnoses including Guillain-Barre syndrome, diabetes mellitus, and lymphedema, was observed applying Medihoney to her left posterior calf wound without an assessment for her ability to self-administer treatments. The facility's policy requires that a resident may only self-administer medications after the interdisciplinary team has determined it is safe, and this assessment must be documented in the resident's medical record. R5 was found with a clear plastic bag containing various ointments and creams, including Medihoney, which she used for her wound care. Despite her severe cognitive impairment, indicated by a BIMS score of 7, there was no documentation of a self-administration assessment in her medical record. The RN/UM confirmed that R5 had not received any teaching regarding self-administration because she was not supposed to perform her treatments. The facility's failure to conduct and document the necessary assessment led to the deficiency noted by the surveyor.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure prompt resolution of grievances filed by two residents, R1 and R3, as required by their grievance policy. R1's representative reported a missing CPAP machine, which was not documented in the facility's grievance log. Despite multiple notifications to staff, including the Admissions Director and Social Worker, there was no evidence of an investigation or resolution communicated to R1's representative. The facility's policy mandates that grievances be tracked, investigated, and resolved with written decisions issued to the complainant, which was not adhered to in this case. R1 was admitted with several medical conditions, including Chronic Obstructive Pulmonary Disease and Vascular Dementia, and required a CPAP machine for treatment. The representative brought the CPAP machine from home, but it went missing during a transfer within the facility. Despite the facility renting a CPAP machine for R1, there was no follow-up or resolution regarding the missing personal CPAP machine, and the grievance was not documented or investigated as per the facility's policy. Similarly, R3's activated Health Care Power of Attorney reported multiple grievances, including care concerns and missing clothing items, to the Social Worker. These grievances were not documented, investigated, or resolved, and no follow-up was provided to R3's representative. R3 had severe cognitive impairments and required assistance with daily activities, making the lack of response to grievances particularly concerning. The facility's failure to document and address these grievances violated their policy and the residents' rights to voice grievances without fear of reprisal.
Failure to Protect Residents During Abuse Investigations
Penalty
Summary
The facility failed to ensure that all allegations of potential abuse were thoroughly investigated and that residents were protected from further abuse during the investigation process. In the first incident, a resident-to-resident altercation occurred where one resident approached another, pulled their hair, and possibly slapped them. Although the facility submitted the required reports to the State Agency and interviewed staff members, they did not conduct interviews with other residents to determine if there was a pattern of abuse or if other residents had witnessed the altercation. This lack of thorough investigation was highlighted during a surveyor's interview with the Nursing Home Administrator, who could not provide additional information or documentation of resident interviews. In the second incident, a Certified Nursing Assistant (CNA) was accused of verbally abusing a resident by telling them to use their incontinent product and slamming a bedpan on the table. The resident reported the incident to a nurse, and an investigation was initiated. However, the CNA was allowed to continue working on the floor with other residents during part of the shift, which is against the facility's policy of removing the accused employee from resident care areas during an investigation. The Director of Nursing initially allowed the CNA to return to the unit before eventually having them leave the facility. This failure to protect residents during the investigation was confirmed by staff interviews and the facility's documentation. The facility's policies on abuse prevention and investigation were not fully adhered to, as evidenced by the lack of immediate removal of the accused CNA from resident care areas and the incomplete investigation into the resident-to-resident altercation. The facility's policy requires thorough investigations, including interviewing all involved parties and ensuring residents are protected from harm during investigations. The surveyor noted that the facility's policy did not explicitly document the procedure for removing an employee from resident care areas immediately after an allegation is made, which contributed to the deficiency in handling the abuse allegations.
Deficiencies in Resident Care and Assessment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident R5, who has severe cognitive impairment and multiple diagnoses including Guillain-Barre syndrome and diabetes mellitus, was observed performing her own wound care treatment on her left posterior calf. Despite the physician's order for daily wound care by nursing staff, R5 was found to be self-administering the treatment due to perceived delays in care. The nursing staff, including RN-J, acknowledged that R5 performed her own treatment and signed the treatment administration record (TAR) as if the treatment was completed by staff, which was not in compliance with the facility's policy. Additionally, the facility did not conduct appropriate assessments for Resident R3, who was admitted with severe cognitive impairment and multiple health conditions. R3 was equipped with a wander guard without a completed wandering assessment, and there was no documentation to support the decision for its placement. Furthermore, R3 was identified as a smoker, yet no smoking assessment was completed to determine the safety and supervision needs for smoking. The lack of assessments and documentation regarding R3's wandering and smoking behaviors indicates a failure to adhere to the facility's policies and procedures for managing residents at risk for elopement and smoking-related incidents. The deficiencies highlight the facility's failure to provide care in accordance with residents' comprehensive assessments and care plans. The lack of proper documentation and adherence to policies resulted in residents not receiving the necessary evaluations and interventions to ensure their safety and well-being. The facility's staff, including the Director of Nursing and Nursing Home Administrator, were informed of these issues, but no further information was provided to address the deficiencies at the time of the survey.
Lack of Behavior Monitoring for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, was receiving psychoactive medications with proper indications and monitoring. R7 was admitted with diagnoses including Unspecified Dementia with Agitation, Anxiety Disorder, and Disorientation, and was prescribed Donepezil and Olanzapine for dementia-related behaviors. Despite the comprehensive care plan requiring behavior monitoring to determine the effectiveness and side effects of these medications, there was no documented behavior monitoring on R7's Medication Administration Record (MAR) since their admission. During the survey, the Director of Nursing (DON) confirmed that behavior monitoring should be documented every shift on the MAR, but acknowledged that this had been missed for R7. The surveyor observed R7 on multiple occasions resting quietly without signs of distress or adverse behaviors, yet the lack of documented monitoring raised concerns about the appropriateness of the psychoactive medication regimen. The Nursing Home Administrator was informed of the deficiency, but the facility was unable to provide additional information or documentation to address the surveyor's concerns.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of appropriate hand hygiene and personal protective equipment (PPE) usage during incontinence care for a resident identified as R10. The resident, who has diagnoses including major depressive disorder, diabetes mellitus, morbid obesity, and altered mental status, also has Stage 3 pressure injuries on the coccyx and left buttocks, necessitating enhanced barrier precautions (EBP). However, during multiple observations, surveyors noted the absence of EBP signage on R10's door and a PPE cart outside the room, which are required by the facility's policy. On several occasions, surveyors observed that staff members, specifically CNA-G and CNA-H, did not wear gowns while providing incontinence care to R10, who was on EBP. Additionally, CNA-G failed to perform proper hand hygiene after removing gloves and before donning new ones during the care process. This lack of adherence to hand hygiene protocols was confirmed by the surveyor's observations, as hand hygiene was only performed at the end of the care session. When questioned, CNA-G was unable to explain how she knew if a resident was on EBP, indicating a lack of awareness or training regarding the facility's infection control policies. Further interviews with the facility's staff, including the RN/UM, DON, and ADON, revealed inconsistencies in the understanding and implementation of EBP. The RN/UM was not aware that R10 was on EBP, despite the resident's pressure injuries, and there was no clear communication or documentation system in place to inform staff of residents requiring EBP. The DON and ADON acknowledged the deficiencies observed by the surveyor, including the absence of EBP signage and PPE carts, as well as the failure of staff to wear gowns and perform proper hand hygiene during care activities.
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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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