Avina Of Kenosha
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenosha, Wisconsin.
- Location
- 3100 Washington Rd., Kenosha, Wisconsin 53144
- CMS Provider Number
- 525179
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Avina Of Kenosha during CMS and state inspections, most recent first.
A cognitively intact resident with cancer metastatic to bone and a history of stroke developed a new stage 3 pressure ulcer on the left heel, documented with specific measurements and sanguineous drainage, and wound care orders were initiated. However, there was no documentation that any family member was informed of this significant change in condition, and a family member later reported not being notified of the wound. An RN stated the resident had not specified whether family should be notified and had no designated representative, and also acknowledged there was no EMR documentation that the resident was asked about or declined family notification, despite facility policy requiring notification of a designated family member for significant health status changes in competent residents.
A resident with severe cognitive impairment and a high risk for falls experienced a fall after sliding out of a wheelchair when a required non-slip Dycem material was not in place, despite this intervention being documented in the care plan and CNA Kardex. The absence of Dycem was confirmed by both the CNA and unit manager, and the facility's investigation identified this omission as the root cause of the fall.
Surveyors found that kitchen staff did not consistently use proper hair restraints or follow sanitary food handling procedures, including failing to restrain facial hair and not cleaning thermometer probes between foods. These actions occurred during meal preparation and service, potentially affecting all residents receiving meals from the main kitchen.
The facility submitted inaccurate PBJ staffing data to CMS for a quarter, resulting in a trigger for low weekend staffing, despite internal schedules showing no gaps. Interviews with the scheduler and DOR indicated no staffing concerns and no use of agency staff, but the DOR did not investigate system alerts about low staffing, and the NHA was unaware of any issues.
Several admission and annual MDS assessments were not completed within the required timeframes due to staffing shortages in the MDS coordinator team. An LPN responsible for MDS assessments was on extended medical leave, and although some support was provided by coordinators from other facilities, the coverage was insufficient, resulting in multiple late or incomplete assessments.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period after assessment, as evidenced by a review of assessment records and transmission logs.
A cook prepared pureed cornbread for several residents on a pureed diet without following the facility's standardized recipe, using unmeasured ingredients and resulting in an incorrect food consistency. The Dietary Manager confirmed that recipes are required for all pureed foods and that the cook did not adhere to this policy.
A resident with multiple medical conditions reported concerns about not consistently receiving double meal portions as requested. The concern was communicated to a CNA Scheduler, but no grievance form was completed, and the issue was only addressed verbally with the Dietary Manager. The resident's care plan and meal tickets did not reflect the request, and the grievance was not documented or formally resolved according to facility policy.
A resident’s quarterly MDS assessment was not completed within the required timeframe due to staffing shortages in the MDS coordinator team. The full-time LPN responsible for assessments was on medical leave, and although assistance was provided by coordinators from other facilities, the coverage was insufficient, resulting in a late assessment.
Two residents did not have their care plans revised or care conferences completed as required. One resident's care plan lacked focus areas for hearing deficit and depression, despite documented needs, and was not updated until well after admission. Another resident did not have a care conference scheduled after a quarterly MDS assessment and was unaware of the process. Staff interviews confirmed delays and omissions in care planning and conference scheduling.
A resident's privacy was compromised due to a faulty door that did not stay closed, an issue persisting since September. The resident, who was cognitively intact and admitted with osteoarthritis, used a towel and pillowcase to keep the door shut, as suggested by a CNA. The Administrator acknowledged the problem, attributing it to weather-related issues, but the Unit Manager/RN was unaware of the door's condition, indicating a lack of communication regarding maintenance work orders.
A facility failed to document and potentially administer insulin and a fingerstick blood sugar test (FSBS) for a resident with type one diabetes. The resident's Medication Administration Record (MAR) showed missing entries for insulin administration and FSBS on two occasions. The Director of Nursing confirmed that the responsible nurse forgot to document due to being busy, but it was unclear if the insulin or FSBS was administered, placing the resident at risk for serious medical consequences.
Two residents' MAR and TAR were incomplete, failing to document medication and wound care treatments. Despite administration, nurses did not record these due to being busy or forgetting, as confirmed by the DON.
The facility did not follow the prescribed menu for all resident diets, affecting 81 residents. Observations revealed discrepancies in portion sizes served compared to the menu specifications. Residents on regular and mechanical soft diets received less Chicken Cacciatore and carrots than prescribed, while those on puree diets received less puree chicken. The Dietary Manager confirmed the menu was not followed, and residents reported insufficient food during meals.
The facility failed to maintain safe water temperatures, with readings ranging from 81 to 139 degrees Fahrenheit, affecting 36 residents. The Maintenance Employee checked temperatures at hot water tanks weekly but did not consistently monitor or document temperatures in resident rooms. The Administrator and Regional Nurse Consultants were unaware of a water temperature policy, and monitoring logs did not include resident bathrooms or shower rooms.
The facility failed to maintain a functioning call system with auditory alarms in the North station, affecting 22 residents. The call light panel did not work, and staff were unaware of how long it had been non-functional. Observations confirmed that while call lights over room doors were operational, the panel at the nurse's station neither lit up nor made noise. The issue persisted for about a month without a formal work order being submitted, despite being reported verbally.
A resident with COPD was not provided with a physician's order for oxygen therapy, despite being tried on oxygen due to low oxygen saturations. The resident's care plan did not include oxygen therapy, and the deficiency was noted when the resident was sent to the hospital for low oxygen saturation. The DON acknowledged that the oxygen order was not processed.
A resident was at risk due to improper medication administration via a g-tube. An LPN combined multiple medications into a single cup without a physician's order, contrary to the facility's policy requiring separate administration with water flushes between each medication. The LPN was unaware of the policy, and the DON expected adherence to it.
The facility failed to ensure that residents with pressure injuries received necessary treatment and services, leading to the development and deterioration of pressure injuries. The facility did not perform necessary skin checks, obtain written orders for PRAFO boots, or update care plans in a timely manner, resulting in immediate jeopardy and actual harm to residents.
The facility failed to ensure adequate assistance devices for two residents, leading to a fracture for one resident during an improper transfer and the absence of a required fall mat for another high-risk resident. These deficiencies indicate a lack of adherence to Care Plans and fall prevention protocols.
A resident with an indwelling catheter experienced multiple hospitalizations due to sepsis from catheter-associated UTIs. Despite being cognitively intact and having a history of urinary retention, there was no documentation of a conversation about the risks and benefits of maintaining the catheter. The facility failed to document any formal assessment or attempt to remove the catheter, leading to repeated infections and hospitalizations.
The facility failed to properly date and label food items in the cooler and freezer, as observed during a kitchen inspection. Additionally, a large exhaust/vent above the dishwasher was found in poor condition, with duct tape used as a temporary fix. The vent had been obsolete since a new dishwasher was installed eight months prior. Staff interviews revealed a lack of awareness and action regarding these issues.
The facility failed to maintain a sanitary garbage storage area, with open lids on full bins and debris scattered around, as observed by surveyors. Staff interviews revealed that due to being short-staffed over the weekend, the responsibilities of ensuring closed lids and cleanliness were neglected, leading to the deficiency.
The facility's infection prevention and control program was deficient due to inadequate tracking and analysis of infection data. The Infection Preventionist was unfamiliar with the computer-based program, leading to discrepancies in infection records. Outbreaks of COVID-19 and RSV were not properly documented or managed, and the facility failed to implement effective surveillance and data analysis as outlined in their manual.
A resident sustained a fractured right tibia and fibula after a CNA did not follow the Care Plan for transfers, opting for a pivot transfer instead of using a sit-to-stand lift. The incident was not reported to the State Agency as required, as the Nursing Home Administrator and Regional Consultant incorrectly determined it was not a reportable event.
The facility failed to revise care plans for two residents and did not hold quarterly care conferences to ensure resident input. One resident's care plan was not updated to include showers twice a week, and another resident did not have care conferences on a quarterly basis, leading to deficiencies in their care.
A resident with severe cognitive impairment was not treated with dignity during meals, as staff stood while feeding and used the term 'feeder'. The CNA did not communicate with the resident about the meal and was observed watching TV. The facility's policy emphasizes promoting dignity and avoiding such labels.
A facility did not resubmit a PASARR Level I screen for a resident with Paranoid Schizophrenia and Bipolar Disorder after a 30-day exemption expired. The resident remained in the facility beyond the exemption period without a subsequent Level II screen. This was confirmed during a record review and an interview with the DON.
A resident on Eliquis, an anticoagulant, was not monitored for adverse effects such as bleeding or bruising, despite being at high risk for falls. The facility lacked a care plan for this medication, and the RN supervisor confirmed that monitoring was not typically done for Eliquis. The deficiency was noted by a surveyor, who found no interventions in the resident's care plan to address potential adverse reactions.
A resident prescribed Seroquel for anxiety did not receive the required AIMS assessment to monitor for side effects, as per facility policy. The resident, admitted with Anxiety, Depression, and Traumatic Brain Injury, was not assessed at the time of admission or when the medication was prescribed. The DON confirmed the oversight.
Failure to Notify Family of New Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident’s family of a significant change in condition when a new stage 3 pressure ulcer was identified. The resident was admitted with diagnoses including cancer with metastasis to the bone and a history of stroke, and an admission MDS showed a BIMS score of 13/15, indicating the resident was cognitively intact. On 10/28/25, a wound care note documented a newly identified stage 3 pressure ulcer on the left heel measuring 5.0 x 5.0 x 0.2 cm with 100% sanguineous drainage, and an order was entered for daily and PRN wound care with normal saline, Medi honey, ABD pad, and kerlix. There was no documentation in the EMR that any family member was informed of this newly identified wound. During an interview, the resident’s family member stated he was not notified of any wound. In a separate interview, the RN reported that the resident was considered “his own person” and had not specified who or whether he wanted family notified of the wound, noting that the resident had three emergency contacts and no designated resident representative. The RN also acknowledged there was no documentation in the EMR that the resident had been asked about family notification or that he declined such notification. The facility’s “Notification of Change in Condition” policy stated that for competent individuals, the facility must still contact the resident’s physician and notify the resident’s representative, if known, and that when a resident is mentally competent, a designated family member should be notified of significant changes in health status because the resident may not be able to notify them personally.
Failure to Implement Fall Prevention Intervention Results in Resident Fall
Penalty
Summary
A resident with severe vascular dementia, type 2 diabetes, and generalized osteoarthritis, who was assessed as being at high risk for falls, did not receive adequate supervision and assistance to prevent accidents. The resident's care plan included the use of Dycem, a non-slip material, in the wheelchair to prevent sliding and falls. On the date of the incident, the resident slid out of the wheelchair and fell to the floor; it was confirmed that the Dycem was not in place at the time of the fall. The facility's policy requires that individualized care plans and interventions, such as the use of Dycem, be communicated to all appropriate staff and implemented to prevent avoidable accidents. The resident's CNA Kardex also documented the need for Dycem in the wheelchair. Interviews and record reviews revealed that the CNA responsible for the resident did not ensure the Dycem was in place at the beginning of the shift, as required. The CNA acknowledged that the intervention was supposed to be checked but was not, and both the CNA and the unit manager confirmed that the absence of Dycem led to the fall. The facility's investigation determined that the root cause of the fall was the missing Dycem in the wheelchair, which was an established intervention for this resident. The resident was found on the floor without injury, and it was noted that the correct wheelchair cushion was present, but the Dycem was not. The deficiency was identified through interviews, record reviews, and the facility's own investigation, which confirmed that the required fall prevention intervention was not implemented at the time of the incident.
Failure to Maintain Sanitary Food Handling and Hair Restraint Practices in Kitchen
Penalty
Summary
Surveyors observed that food was not stored, prepared, and served under sanitary conditions in the facility's main kitchen. Specifically, a cook was seen pureeing food and preparing meal trays without a proper facial hair restraint, leaving his mustache exposed throughout food preparation and service. Additionally, the same cook failed to clean the thermometer probe between checking different food items. A dietary aide was also observed handling exposed, ready-to-eat foods with hair not fully contained under a hair restraint. These practices were witnessed during meal preparation and service, with both staff members directly handling food intended for residents. The facility's policy requires all dietary staff to wear appropriate hair restraints, including beard nets for facial hair, and to follow safe food handling procedures. The dietary manager confirmed these requirements during an interview and acknowledged observing the improper use of hair restraints but did not intervene at the time. The deficient practices had the potential to affect all 90 residents who received meals from the main kitchen, as all food for the facility is prepared and served there.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure that the mandatory staffing data submitted to CMS for the second quarter of 2025 was accurate and based on payroll and other verifiable and auditable data, as required. During a review of the Payroll-Based Journal (PBJ) staffing data, the facility was flagged for excessively low weekend staffing, which had the potential to affect all 90 residents. The facility's own assessment documented staffing needs and also triggered for low weekend staffing during the same period. However, upon review of nursing schedules and posted staff hours, no documented trends or gaps in weekend staff coverage were found. Interviews with the scheduler and the Director of Recruitment (DOR) revealed that the facility does not use agency staff and typically overstaffs on weekends to cover call-ins, with no reported staffing concerns. The DOR, responsible for submitting PBJ reports, stated that the system alerted them to being in the bottom 20th percentile for staffing, but did not investigate the cause of this alert, which affected all company facilities. The Nursing Home Administrator (NHA) was not aware of any staffing alerts or low weekend staffing. No further information was provided to explain why the submitted staffing data was inaccurate or did not align with verifiable records.
Failure to Complete MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete admission and annual comprehensive Minimum Data Set (MDS) assessments within the required timeframes for six out of eight residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, admission MDS assessments must be completed by the end of day 14 after admission, and annual assessments must be completed at least every 366 days. The report details that several residents had their admission or annual MDS assessments either completed late or still in progress well past the required deadlines. For example, one resident's admission MDS was completed 24 days late, another's annual MDS was still in progress at the time of survey, and others had similar delays or incomplete assessments. The deficiency was attributed to staffing issues within the MDS coordinator team. The full-time LPN responsible for MDS assessments had been on medical leave for three months, and although coordinators from sister facilities provided some assistance, the extent of their coverage was unclear. The LPN and the Nursing Home Administrator both acknowledged awareness of the late assessments and attributed the delays to difficulties in staffing the MDS coordinator position during the period in question. No additional information regarding the residents' medical histories or conditions at the time of the deficiency was provided.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. This deficiency was identified based on a review of assessment records and transmission logs, which showed that required assessment data were not submitted to the State within the mandated timeframe. The delay in data transmission was directly related to the facility’s inaction in meeting the 7-day submission requirement following the completion of resident assessments.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
Surveyors observed that the facility did not ensure food was prepared to conserve nutritive value and flavor for residents on a pureed diet. Specifically, a cook was seen preparing pureed cornbread without following a standardized recipe, as required by facility policy. The cook placed unmeasured amounts of cornbread, milk, and thickening powder into a blender, blended the mixture, and produced a consistency thinner than pudding, which did not meet the expected standard for pureed foods. When questioned, the cook was unable to describe the correct consistency or confirm adherence to a recipe. The Dietary Manager confirmed that recipes exist for all pureed foods and acknowledged that the cook should have followed the recipe to achieve the correct texture. The facility's policy mandates the use of standardized recipes for all menu items, and the failure to follow these procedures was observed to affect all residents receiving pureed diets at the facility. No explanation was provided for the cook's deviation from the required process.
Failure to Document and Resolve Resident Grievance Regarding Meal Portions
Penalty
Summary
A deficiency occurred when the facility failed to address and resolve a resident's grievance regarding meal portion sizes. The resident, who was cognitively intact and had multiple medical diagnoses including a left femur fracture, COPD, diabetes, and heart failure, reported concerns about not consistently receiving double portions with meals as requested. The resident communicated these concerns to their assigned caring partner, a CNA Scheduler, but there was no documentation of the grievance in the facility's grievance log, and the resident's care plan and meal tickets did not reflect the request for double portions. The facility's policy requires that all grievances be documented and forwarded to the grievance official, but this process was not followed in this case. Interviews with staff revealed that the CNA Scheduler, who was new to both the facility and long-term care, did not complete a grievance form or report the concern to social services, believing the issue was addressed verbally with the Dietary Manager. The Dietary Manager confirmed the concern was handled verbally and acknowledged that the meal tickets did not reflect the resident's preferences, which was an oversight. The Social Services Director was unaware of the concern and reiterated that all grievances should be documented. The lack of documentation and formal follow-up resulted in the resident's grievance not being properly addressed according to facility policy.
Late Completion of Quarterly MDS Assessment Due to Staffing Shortages
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident’s quarterly Minimum Data Set (MDS) assessment was completed within the required timeframe as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that quarterly MDS assessments must be completed at least every 92 days following the previous assessment, and the completion date must be no later than 14 days after the Assessment Reference Date (ARD). In this case, the resident’s quarterly MDS assessment was completed 20 days after the required deadline. The delay was attributed to staffing challenges within the MDS coordinator team. The full-time LPN responsible for MDS assessments had been on medical leave for three months, and although coordinators from sister facilities assisted during this period, the extent of their coverage was unclear. Upon returning, the LPN and the Nursing Home Administrator acknowledged the late completion of the assessment and cited difficulties in maintaining adequate MDS staffing during the absence.
Failure to Timely Revise Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to revise care plans and conduct timely care conferences for two residents, as required by policy and regulatory standards. For one resident with diagnoses including pneumonia, acute respiratory failure, hypertension, dysphasia, depression, and anxiety, the comprehensive care plan was not completed within the required timeframe after admission. The initial care plan did not include focus areas for hearing deficit or depression, despite documented evidence of moderate depression and a known hearing impairment. The care plan was not updated to address these issues until more than a month after admission, and only after the surveyor brought the omissions to the facility's attention. Interviews with staff revealed a lack of clarity regarding responsibility for updating care plans and acknowledged that the required focus areas were not included initially. Another resident with multiple chronic conditions, including COPD, asthma, morbid obesity, diabetes, congestive heart failure, bipolar disorder, anxiety, depression, panic disorder, and PTSD, did not have a care conference scheduled following a quarterly MDS assessment. The resident was unaware of care conferences and expressed interest in participating. Documentation showed that the last care conference occurred several months prior, and no subsequent conference was scheduled in accordance with the facility's policy and the MDS assessment schedule. Staff interviews confirmed that the care conference had not been held as required and that scheduling was delayed. The facility's policy mandates that comprehensive care plans be developed within seven days of completing the comprehensive MDS assessment and that care conferences be held quarterly or in accordance with the MDS schedule. In both cases, the facility did not adhere to these requirements, resulting in incomplete or delayed care planning and lack of resident involvement in care conferences.
Failure to Ensure Resident Privacy Due to Faulty Door
Penalty
Summary
The facility failed to ensure the proper functioning of a resident's door, compromising the resident's privacy and safety. The resident, who was cognitively intact and admitted with bilateral primary osteoarthritis of the knee, reported that the door to their room did not stay closed, which had been an issue since September. To keep the door shut, a CNA suggested using a towel and pillowcase, which the resident implemented. The resident expressed concern about privacy, particularly when using the commode, as the door's inability to close properly allowed others to see inside. During an observation, it was confirmed that the door latch did not engage with the strike plate, preventing the door from staying closed. The facility's Administrator acknowledged the issue, attributing it to weather-related expansion and contraction. However, the Unit Manager/RN was unaware of the problem, indicating a lack of communication or follow-up on maintenance work orders. This oversight resulted in a failure to maintain a safe and private environment for the resident.
Failure to Document and Administer Insulin and FSBS
Penalty
Summary
The facility failed to ensure proper documentation and administration of a fingerstick blood sugar test (FSBS) and insulin for a resident with type one diabetes. The resident, who was cognitively intact, was admitted with diagnoses including type one diabetes with ketoacidosis and coma. The facility's policy on medication errors emphasizes the importance of verifying the right medication, dose, route, time, resident, and documentation to prevent errors. However, the Medication Administration Record (MAR) for December 2024 showed that insulin Lispro was not documented as administered on two occasions, and there was no record of an FSBS being obtained or insulin being administered as per the sliding scale on the same dates. The Director of Nursing (DON) confirmed during an interview that the registered nurse responsible for the resident's care admitted to forgetting to document due to being busy, but did not confirm whether the insulin or FSBS had been administered. The lack of documentation and potential failure to administer the prescribed insulin and FSBS placed the resident at risk for serious medical consequences, as the resident's condition requires careful monitoring and management of blood sugar levels.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure the Medication Administration Record (MAR) and Treatment Administration Record (TAR) were complete and accurate for two residents. For Resident 10, the MAR did not reflect the administration of several medications as per physician orders. These medications included an antibiotic, a dementia medication, a GERD medication, an iron supplement, a cough syrup, and a breathing medication. The Director of Nursing (DON) confirmed that the medications were administered but not documented by the responsible nurses, RN4 and LPN3. Resident 7's TAR was incomplete, failing to document the administration of wound care treatments for pressure injuries. The treatments were not recorded on multiple occasions, despite the resident confirming that wound care was generally provided. The DON stated that if a resident was out of the facility, the information should be passed to the next shift, and the treatment should be documented as administered or noted that the resident was unavailable. Interviews with the DON revealed that the nurses responsible for administering medications and treatments did not document them due to being busy or forgetting. The expectation was for documentation to occur immediately after administration or to note the resident's absence. The lack of documentation for both residents indicates a failure to adhere to the facility's policy on medication and treatment administration documentation.
Failure to Follow Prescribed Menu for Resident Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for all diets listed on the menu spreadsheet, affecting all 81 residents who receive meals from the facility. During lunch observations, it was noted that the portions served did not match the menu specifications. Specifically, residents on regular and mechanical soft diets were served 5.3 ounces of Chicken Cacciatore mixed with pasta instead of the prescribed 6 ounces of Chicken Cacciatore and 4 ounces of Penne pasta. Additionally, they received 3 ounces of carrots instead of the 4 ounces specified. Residents on puree diets were served 4 ounces of puree chicken instead of the 8 ounces of puree chicken cacciatore and 4 ounces of puree penne pasta as outlined in the menu. Interviews with the Dietary Manager confirmed that the cook was not following the menu for any of the diets. The Dietary Manager acknowledged the discrepancies in portion sizes and confirmed that the menu was not being adhered to. Furthermore, during lunch observations, three unidentified residents expressed that they often did not receive enough food during meals. The Administrator also stated that she expected the menu to be followed, indicating a lack of oversight in ensuring compliance with dietary requirements.
Inconsistent Water Temperature Monitoring in Facility
Penalty
Summary
The facility failed to maintain water temperatures within the safe and comfortable range of 110 to 120 degrees Fahrenheit, as outlined in their policy. Observations and interviews revealed that water temperatures in various units were either too cold or excessively hot, posing potential risks for burn-related injuries or discomfort during showers. Specifically, water temperatures in the South, North, and West units fluctuated significantly, with some readings as low as 81 degrees Fahrenheit and others as high as 139 degrees Fahrenheit. These inconsistencies affected 36 of the 81 residents in the facility, with some residents reporting discomfort during showers and others experiencing dangerously hot water in their sinks. The Maintenance Employee (ME) admitted to checking water temperatures at the hot water tanks weekly but only randomly checking temperatures in resident rooms without documenting them. The facility's Administrator and Regional Nurse Consultants were unaware of a water temperature policy, and the monitoring logs provided did not include temperatures from resident bathrooms or shower rooms. The Administrator confirmed that water temperatures were not regularly monitored in these areas, despite the facility having four shower rooms and 81 resident bathrooms. This lack of consistent monitoring and documentation contributed to the deficiency in maintaining safe water temperatures.
Failure to Maintain Functioning Call System in North Station
Penalty
Summary
The facility failed to maintain a functioning call system with auditory alarms in the North station, affecting 22 residents. The call light panel behind the nursing station did not work, and staff were unaware of how long it had been non-functional. Observations confirmed that while the call lights over individual room doors were operational, the panel at the nurse's station neither lit up nor made noise, which was corroborated by maintenance staff. Interviews with staff, including a Certified Medication Tech, a Registered Nurse, and a Certified Nurse Aid, revealed that the issue had persisted for about a month, and although it was reported verbally, no formal work order had been submitted until the surveyor's visit. The maintenance employee confirmed the malfunction and indicated that the system was too old for repair by several companies, though a potential solution was being explored. The facility's policy required call light system defects to be reported to the Maintenance Department for servicing, but this protocol was not followed, as evidenced by the lack of a work order. The Administrator acknowledged the issue and confirmed that while the visual alert was functional, the auditory alarm was not, and she had only verbally informed the maintenance staff without submitting a work order initially.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure there was a physician's order for oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD). The resident was readmitted to the facility and was not initially assessed as using oxygen during the assessment period. The resident's care plan included interventions for COPD but did not mention oxygen therapy. A review of the resident's physician orders revealed no order for oxygen therapy, despite the resident being tried on oxygen due to low oxygen saturations. The deficiency was highlighted when the resident was sent to the hospital emergently for low oxygen saturation. The resident's oxygen saturation improved after increasing the oxygen from 2L to 5L. A pulmonologist's note indicated that the resident was using 3L of oxygen and felt better with it. However, the Director of Nursing acknowledged that the oxygen order was not processed, leading to the deficiency in providing appropriate respiratory care.
Failure to Follow G-Tube Medication Administration Policy
Penalty
Summary
The facility failed to adhere to its medication administration policy for a resident who was ordered to receive medications via a gastrostomy tube (g-tube). The resident, identified as R8, had specific medication orders that required each medication to be administered separately with a flush of tepid water between each to prevent the g-tube from becoming clogged. However, during an observation, an LPN was seen preparing to administer multiple medications as a cocktail, combining them into a single cup without a physician's order to do so. This action was contrary to the facility's policy, which mandates the separate administration of medications. The incident involved the administration of Docusate Sodium, Keppra, Guaifenesin, and Famotidine, with the latter being crushed and mixed with the liquid medications. The LPN was unaware of the facility's policy regarding the administration of medications via a g-tube, which was confirmed during an interview. The Director of Nursing later stated that it was expected for the LPN to follow the facility's policy, highlighting a lapse in adherence to established procedures for medication administration.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing. Specifically, the facility did not perform checks each shift to monitor the skin under PRAFO boots for a resident, leading to the development of a stage 4 pressure injury. The facility also failed to obtain written orders on the length of time the PRAFO boots should be worn and did not update the resident's plan of care for over a month regarding the pressure wound. A comprehensive assessment of the wound was not documented until the wound doctor saw the resident on 2/5/2024, despite the wound being discovered on 1/30/2024. This created a finding of Immediate Jeopardy at a scope and severity of a J (immediate jeopardy/isolated) that began on 1/30/2024. The immediate jeopardy was removed on 4/24/2024 when the facility implemented their action plan, but the deficient practice continued at a scope and severity of a G (actual harm/isolated) for other residents reviewed for pressure injuries. Another resident was admitted to the facility from the hospital with an unstageable pressure injury on the coccyx, which deteriorated to a stage 4 pressure injury with multiple courses of antibiotics after admission. The resident developed multiple infections related to possible soiled dressing from stool that were not addressed in the treatment record to change dressings as needed. The resident's air mattress was observed set to a higher weight load than what the resident weighed, and the facility did not establish a clear, individualized plan of care regarding repositioning for the resident. Additional observations included residents with air mattresses set to incorrect weight loads, a resident developing a facility-acquired stage 3 pressure injury due to the lack of an individualized repositioning schedule, and another resident with a sacral pressure injury and a chronic left heel pressure injury that was not comprehensively assessed by a Registered Nurse until days after the wound reopened. The facility's policy and procedure for pressure ulcers/skin integrity/wound management were not followed, leading to these deficiencies.
Removal Plan
- R78 no longer uses his PRAFO boots.
- Orders for splint/brace and skin integrity checks will be reviewed by nursing and initiated.
- Care plans have been reviewed and reflect the use of the splint/brace.
- Any new or worsening skin integrity issues will require a documented comprehensive RN assessment. This will include physician notification and care plan review.
- Nursing staff to be educated on identifying a splint/brace along with the risk for skin breakdown related to the device.
- Nursing staff to be educated on following the wearing schedule for splint/braces and completing skin integrity checks according to the plan of care.
- Nursing staff will receive education on the need for an RN assessment when any new or worsening wound is found.
- Facility reviewed the policy for prevention of pressure injuries.
- Medical Director is aware and involved in plan.
- DON/designee will audit all brace/splint monitoring orders and wearing schedules to ensure completion.
- DON/Nurse Managers will audit skin checks for braces/splints to ensure compliance.
- Results of audits will be reviewed through the QAPI process and make changes as necessary.
Failure to Follow Care Plans and Use Assistive Devices
Penalty
Summary
The facility did not ensure that residents received adequate assistance devices to prevent accidents for two residents. One resident, R65, was transferred using a pivot transfer instead of the sit-to-stand lift as indicated in their Care Plan. During the transfer, R65's leg became trapped, resulting in a fracture of the right tibia and fibula. The investigation revealed that the CNA did not follow the Care Plan and performed a pivot transfer based on the resident's request, leading to the injury. The resident was subsequently treated at the hospital and readmitted with an external fixation device and non-weight bearing instructions for the right leg. Another resident, R67, was observed multiple times without a fall mat in place as required by their Care Plan. Despite being at high risk for falls, the fall mat was not found on the right side of the bed during several observations. The LPN confirmed that the fall mat should have been in place, but it was not. This lack of adherence to the Care Plan posed a significant risk to the resident's safety. These deficiencies highlight the facility's failure to implement and maintain individualized fall prevention strategies as outlined in their Fall Prevention Program. The lack of proper supervision and use of assistive devices directly contributed to the accidents involving R65 and R67, indicating a need for improved adherence to Care Plans and staff training on fall prevention protocols.
Failure to Assess Indwelling Catheter Removal
Penalty
Summary
The facility did not ensure that a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible. The resident, who was admitted with a urinary catheter, had multiple hospitalizations due to sepsis caused by catheter-associated urinary tract infections (UTIs). Despite being cognitively intact and having a history of urinary retention, there was no documentation of a conversation with the resident about the risks and benefits of maintaining the catheter. Additionally, there was no evidence that the catheter was recommended for wound healing by a wound physician, even though it was cited as a reason for its continued use. The resident had a significant medical history, including malnutrition, anorexia, diabetes, polyneuropathy, adult failure to thrive, and depression. The resident's care plan included monitoring for catheter complications and pain, but there was no documentation of a voiding trial to assess the necessity of the catheter. The resident expressed a preference for keeping the catheter due to limited mobility and convenience, but this preference was not adequately documented or assessed for medical necessity. Interviews with nursing staff revealed a lack of clarity about whether a voiding trial had been attempted and whether the resident had been informed of the risks associated with long-term catheter use. The resident experienced multiple episodes of catheter clogging and leakage, which were not promptly addressed. The facility failed to document any formal assessment or conversation regarding the removal of the catheter, leading to repeated infections and hospitalizations for the resident.
Deficiencies in Food Storage and Kitchen Ventilation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen inspection. In the reach-in cooler, a large open bag of shredded cheese and two large pieces of uncooked pork were found without proper labeling or dating. The Dietary Manager was unable to provide an explanation for the oversight, indicating that the cook should have dated and labeled the foods. Additionally, in the kitchen freezer, a large box of uncovered lettuce with brown edges and an open bag of Hormel Breakfast Sausage Crumble were found without dates, further highlighting the facility's failure to comply with its own food storage policy. Another significant issue was identified with the kitchen's exhaust/vent system. A large silver metal exhaust/vent located above the dishwasher was observed to be in poor condition, with red duct tape wrapped around it and cold air blowing directly in front of the dishwasher. The vent had been in this state since the installation of a new dishwasher eight months prior, and the maintenance staff admitted to using duct tape as a temporary fix. The vent was originally part of the old dishwasher's exhaust system and was deemed obsolete with the new dishwasher installation. Interviews with the facility's staff, including the Dietary Manager, Maintenance Assistant, and Maintenance Director, revealed a lack of awareness and action regarding the exhaust/vent issue. The Registered Dietician confirmed that the responsibility for dating and labeling foods lay with the dietary manager or cooks. The facility's Administrator acknowledged the presence of the outdated exhaust/vent system since the new dishwasher's installation but had not addressed the issue until the surveyor's observation.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to maintain the outside garbage storage area in a sanitary condition, as observed by surveyors. On the first observation, three large metal garbage bins were found to be full with their lids open, and the surrounding area was littered with various debris, including garbage bags, paper cups, medication cups, Styrofoam cups, used gloves, and a soiled adult brief. A metal rodent trap was also noted to be empty. The Dietary Manager acknowledged that the area should be clean and the lids should be closed, indicating a lapse in maintaining the area as per the facility's pest control policy. Further interviews revealed that the Maintenance Director and Plant Operations Manager were aware that the lids should always be closed and the area kept clean. However, due to being short-staffed over the weekend, these tasks were not completed, leading to the observed unsanitary conditions. The Plant Operations Manager admitted that the CNAs and other staff were responsible for ensuring the cleanliness and closure of the garbage bins, but due to staffing issues, these responsibilities were neglected, resulting in the deficiency.
Inadequate Infection Control Program and Data Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by inadequate tracking, trending, and analysis of infection data. The Infection Control Program did not accurately identify infections within the facility, and there was no system of surveillance, including mapping to identify monthly infections on units. The Infection Preventionist (IP) was not familiar with the computer-based Infection Prevention program, which hindered the facility's ability to analyze and maintain infection data effectively. The facility experienced an outbreak of COVID-19 in December 2023 and two outbreaks of RSV in March and April 2024. However, there were no summaries, timelines, contact tracing, or documentation explaining the course of these outbreaks or the steps taken to mitigate them. The surveyor noted discrepancies between handwritten line lists and the computer-generated infection control log, indicating a lack of accurate record-keeping and data analysis. Interviews with the IP and facility administrators revealed that the IP was new to the position and lacked training in using the computer program for infection data analysis. The facility's Infection Prevention and Control Manual outlined the necessary elements of a surveillance system, but these were not effectively implemented. The surveyor's review of the facility's documentation and interviews with staff highlighted significant gaps in the infection prevention and control program, contributing to the deficiency.
Failure to Report Incident of Neglect Resulting in Serious Injury
Penalty
Summary
The facility failed to report an incident of neglect that resulted in serious bodily injury to the State Agency. A resident, who was dependent on staff for transfers and required the use of a sit-to-stand lift as per their Care Plan, was transferred by a CNA using a pivot transfer instead. This deviation from the Care Plan led to the resident sustaining a fractured right tibia and fibula. The incident was not reported to the State Agency as required by the facility's policy and procedure on abuse and neglect reporting. The resident, who had diagnoses including malnutrition, diabetes, and moderate cognitive impairment, complained of severe pain in the right leg following the improper transfer. The resident was subsequently transported to the hospital for evaluation and treatment, where the fractures were confirmed. The CNA involved in the incident admitted to not following the Care Plan, citing the resident's preference and previous therapy sessions as reasons for attempting the pivot transfer. The Nursing Home Administrator and Regional Consultant reviewed the incident and determined it was not intentional and did not fit the definition of abuse, thus deciding it was not a reportable event. However, this decision was based on a flow chart not intended for nursing home use, leading to the failure to report the incident to the State Agency within the required timeframe.
Failure to Revise Care Plans and Hold Quarterly Care Conferences
Penalty
Summary
The facility did not revise resident care plans for two residents and failed to ensure care conferences were held quarterly to get resident input in their care. One resident's care plan was not updated to include showers twice a week as discussed with the resident's guardian, resulting in the resident not receiving the agreed-upon showers. The resident had severe cognitive impairment and required substantial assistance for personal hygiene, including the use of a Hoyer lift for transfers. Despite a grievance filed by the resident's guardian, the care plan and care Kardex were not revised to reflect the new shower schedule, and the resident's medication administration record showed inconsistent documentation of shower days. Another resident did not have care conferences on a quarterly basis to ensure participation in the development of their care plan. The resident had moderate cognitive impairment and required substantial assistance for daily activities. The facility's policy stated that care plan conferences should be held at least quarterly, but documentation showed significant gaps between care conferences. The resident's first care conference was held several months after admission, and subsequent conferences were not held quarterly as required. The lack of documentation and follow-up on scheduled care conferences indicated a failure to adhere to the facility's policy. Interviews with staff, including social services and the unit manager, revealed a lack of communication and follow-through regarding grievances and care plan updates. The unit manager did not recall the specific concerns about the resident's shower schedule, and social services did not have documentation of care conferences for the second resident. The facility's failure to revise care plans and hold regular care conferences led to deficiencies in the care provided to the residents.
Failure to Ensure Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure dignity for a resident during meal times, as observed in two separate instances. The resident, who has severe cognitive impairment due to Alzheimer's disease and other forms of dementia, requires substantial assistance with eating. During a breakfast observation, a Certified Nursing Assistant (CNA) was seen standing while feeding the resident, without engaging in any communication about the meal. The CNA was also observed watching television instead of interacting with the resident, who was non-communicative and reliant on the CNA for feeding. In a subsequent meal observation, the same CNA was again standing while feeding the resident and did not communicate what the resident was eating. Another staff member, the HR Coordinator, temporarily took over feeding duties and also stood while interacting minimally with the resident. The CNA and HR Coordinator conversed with each other over the resident, who remained non-communicative and dependent on the staff for feeding. Interviews with the CNA revealed a preference for standing while feeding residents, and the use of the term 'feeder' to describe residents requiring assistance with meals. The facility's Administrator expressed that staff should engage with residents during meals and should not refer to them as 'feeders'. The facility's policy emphasizes promoting resident dignity and avoiding labels such as 'feeders', as well as encouraging staff to sit while assisting residents with meals.
Failure to Resubmit PASARR Level I for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure compliance with the Preadmission Screening and Resident Review (PASARR) process for a resident diagnosed with Paranoid Schizophrenia and Bipolar Disorder. The resident was admitted with a PASARR Level I screen that included a 30-day exemption due to a hospital discharge and an expected short-term stay. However, when the resident remained in the facility beyond the 30-day exemption period, the facility did not resubmit a PASARR Level I screen to the State mental health authority, nor was a subsequent Level II screen completed. This oversight was confirmed during a record review and an interview with the Director of Nurses, who acknowledged that the necessary PASARR Level I should have been completed after the 30-day period expired.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the anticoagulant Eliquis. The resident, who has multiple diagnoses including end-stage renal disease, diabetes, and vascular dementia, was admitted with an order for Eliquis to be taken twice daily. However, the facility did not implement a care plan or orders to monitor for adverse side effects associated with the anticoagulant, such as bleeding or bruising. This oversight was noted despite the resident's high risk for falls, which increases the risk of bleeding when on an anticoagulant. The surveyor's review of the resident's medication administration record and comprehensive care plan revealed a lack of monitoring for signs and symptoms of adverse effects from Eliquis. During an interview, the registered nurse supervisor indicated that typically only Coumadin or Warfarin are monitored and care planned, and there was no specific plan for monitoring Eliquis. The surveyor found no interventions related to monitoring for adverse reactions in the resident's cardiovascular care plan. These findings were shared with the nursing home administrator, who did not provide further information at the time.
Failure to Conduct AIMS Assessment for Resident on Anti-Psychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving anti-psychotic medication was assessed for potential side effects. Specifically, a resident identified as R82, who was prescribed Seroquel for anxiety, did not have an Abnormal Involuntary Movement Scale (AIMS) assessment completed as required by the facility's policy. The policy mandates that such an examination be performed at the time of admission or when the medication is initially prescribed. R82 was admitted with diagnoses including Anxiety, Depression, and Traumatic Brain Injury, and was prescribed Seroquel on 3/22/24. However, upon review of R82's medical records on 4/23/24, no AIMS assessment was found. The Director of Nurses confirmed that the assessment was not completed, acknowledging the oversight.
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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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