Avina Of Milwaukee
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 9255 N 76th St, Milwaukee, Wisconsin 53223
- CMS Provider Number
- 525523
- Inspections on file
- 30
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Avina Of Milwaukee during CMS and state inspections, most recent first.
The facility failed to conduct and document required quarterly, interdisciplinary care plan conferences that allow resident and family participation in person-centered care planning. One cognitively intact resident reported that scheduled care conferences never occurred and record review confirmed no quarterly conferences over several months. Another resident with severe cognitive impairment and multiple chronic conditions had no documented care conferences, and the SW responsible for conferences acknowledged none had been completed. A third resident with Alzheimer’s disease and other comorbidities had no evidence of a care conference in the prior year, and the SW confirmed not having held any, with no supporting documentation available when leadership was informed.
A cognitively intact resident with multiple chronic conditions, including cervical radiculopathy, BPH, adult failure to thrive, pulmonary HTN, and depression, reported to an RN that two night-shift CNAs had "roughed him up" while providing ADL care, including allegedly holding his wrists and pulling him while changing his brief despite his insistence that he was not wet. The RN documented the complaint, notified the DON, and obtained CNA statements, but the allegation of potential abuse was not reported to the State survey agency or the NHA as required by the facility’s abuse, neglect, and exploitation policy, and the NHA later confirmed there were no incident reports submitted for this resident during the review period.
A cognitively intact resident with multiple medical conditions, including cervical radiculopathy, BPH, and incontinence, reported that two CNAs insisted on changing him despite his statement that he was not wet, allegedly held his wrists, pulled him causing shoulder pain, and "roughed him up" during nocturnal ADL care. The RN on duty documented the complaint, notified the DON, and obtained written statements from the two CNAs. However, the DON did not interview the resident, the CNAs, or the RN, did not conduct a formal investigation, and only retained the CNA statements. No other residents were interviewed to assess for similar concerns, resulting in a failure to follow the facility’s abuse/neglect investigation policy requiring immediate, thorough investigation and interviews of all involved persons.
A resident with multiple medical conditions, severe cognitive impairment, high fall risk, and specific hospital discharge instructions for diet, supervision, and mobility was admitted, but the facility failed to develop and implement a person-centered baseline care plan within 48 hours. Despite policy requiring individualized goals and interventions based on admission assessments and hospital information, the baseline care plan and CNA Kardex contained generic, incomplete entries that did not specify needed assistance with ADLs, mobility, incontinence care, skin integrity, or fall prevention, and omitted key instructions such as 1:1 supervision and pureed diet with no straws. The DON later acknowledged that the non-specific care plan and Kardex did not provide staff with clear guidance on how to safely care for the resident.
A resident with multiple comorbidities, including dementia and a history of falls, had two unwitnessed falls on the same day, after which staff initiated but did not complete neurological checks as required by facility policy. The policy called for a defined series of neuro assessments (Q15 minutes, then Q1 hour, then Q shift for 72 hours) after unwitnessed falls or head injuries, including evaluation of consciousness, speech, pupils, hand grasps, and vital signs. Documentation showed only partial completion of the ordered neuro‑check sequence after each fall, and the DON confirmed the expected schedule and documentation requirements but could not provide a reason why the full series of checks was not carried out.
Two residents at high risk for falls, both with cognitive impairment and mobility limitations, experienced multiple falls after admission while the facility relied on generic fall interventions such as keeping the call light within reach and following facility protocol. For one resident, therapy and hospital records documented significant balance, judgment, and safety‑awareness deficits, yet the baseline care plan and CNA Kardex lacked specific, person‑centered instructions for bed mobility, transfers, ambulation, and supervision. This resident had three falls within a short period, including two unwitnessed falls and a later witnessed fall at the nurses’ station resulting in a head laceration, but the facility failed to complete thorough fall investigations, obtain staff statements, clarify circumstances of the falls, or perform root cause analyses. The second resident, also care‑planned only with generic fall measures, sustained an unwitnessed fall while getting out of bed, and the fall investigation lacked details on when the resident was last seen or toileted, with the DON confirming no additional information was available.
Surveyors found that the facility did not conduct or document required safety inspections of any of the 77 resident beds, including those with assist or mobility bars. The NHA confirmed there was no policy for bed inspections, and the Maintenance Director reported that while informal checks are done at admission (such as removing safety bars, checking for a mattress, testing remotes, and looking for exposed wires), these checks are not documented. Review of the MIFU for Joerns beds showed a requirement for monthly visual inspections for broken welds, cracks, and loose hardware, which were not documented. Additionally, although FDA guidance on seven bed entrapment zones and dimensional limits was available, the Maintenance Director stated that FDA entrapment zone measurements were not performed or documented for any of the 36 residents using bed rails, mobility bars, or assist bars.
The facility failed to maintain and serve hot food at safe temperatures, as required by its food safety policy and FDA Food Code standards. A cognitively intact resident with severe protein-calorie malnutrition and multiple comorbidities reported that meals were cold and not always reheated by staff. During an observed evening meal, the DM measured the resident’s chicken and noodles at 93.7°F directly from the transport cart, despite policy requiring monitoring of holding temperatures and reheating cooked foods to 165°F or heating ready-to-eat foods to at least 135°F. Federal guidance cited in the report notes that food held in the 40–140°F “Danger Zone” can support bacterial growth and that hot foods should be kept at or above 140°F.
A resident with stroke-related deficits, parkinsonism, left-sided hemiplegia/hemiparesis, and moderately impaired cognition was assessed on the MDS as needing assistance with meal setup and cleanup. During a lunch observation, the resident sat alone with the meal plate still covered in plastic wrap, which he had only partially torn and not fully removed, until the Dining Services Manager removed it and stated that serving staff should have done so. A CNA acknowledged she should have removed the plastic wrap, while the DON and Nursing Home Administrator both stated that CNAs are required and expected to complete meal setup for residents when indicated, consistent with the facility’s ADL policy requiring assistance with meal setup based on assessed needs.
A resident with hypoglycemia, diabetes, and diabetic chronic kidney disease had an order for acarbose 25 mg to be given orally three times daily before meals, but medication records showed repeated late administrations and, on one occasion, two scheduled doses documented at the same time. The NHA reported there was no facility policy on medication administration, and the DON stated medications were expected to be given as ordered, acknowledging that the recorded times fell outside normal leeway and were not properly documented in relation to meal delivery, despite acarbose being intended for administration with the first bite of each meal.
A resident who was cognitively intact and dependent on staff for mobility reported being left for several hours without incontinence care after their ostomy bag broke, despite multiple calls for assistance. Although the concern was brought to the attention of the Director of Social Services and the Nursing Home Administrator, staff did not initiate a formal grievance or conduct an investigation as required by facility policy.
A resident with multiple mental health and medical diagnoses was not re-screened for mental disorders with a PASARR Level 1 after a 30-day exemption expired, despite continued residence in the facility. The initial PASARR indicated a major mental disorder and the exemption, but no follow-up screening was completed as required by facility policy.
A resident with significant medical and cognitive conditions, identified as high risk for falls, experienced three unwitnessed falls. The facility failed to complete thorough post-fall investigations as required by policy, including missing documentation, lack of staff statements, and incomplete root cause analysis, resulting in inadequate supervision and failure to implement effective fall prevention interventions.
A resident with multiple health conditions experienced significant unaddressed weight loss, with no evidence of physician or RD notification or new interventions. Over half of the resident's meal intake records were missing, preventing accurate assessment of nutritional status.
A resident reported inappropriate touching by another resident to a physical therapist, who documented the incident and informed a nurse. The nurse did not escalate the report to the NHA or authorities, resulting in a delay of over twelve hours before the incident was properly reported, contrary to facility policy requiring immediate notification of abuse allegations.
A resident with dementia and depression engaged in inappropriate sexual behavior toward another resident, but the facility did not notify the psychiatric provider or provide medically related social services to address the incident. There was also no documentation of care plan updates or attempts to obtain consent for continued psychiatric services from the resident's POA.
The facility failed to secure resident valuables and prevent the misappropriation of money and personal items, with several residents missing cash and identification from a locked office. Additionally, a nurse diverted narcotic medications from a destruction box, and the required background check for this staff member was not on file, despite her history of license suspension and prior incidents of theft and drug diversion. Facility policies for securing valuables and controlled substances were not consistently followed, leading to these deficiencies.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall. Facility policy required prompt notification of the resident's representative, but no documentation of such notification was found. Interviews with the Administrator, DON, and Medical Records confirmed that the representative was not notified as required.
Two residents were not adequately protected from abuse: one was verbally abused by a CNA after spilling food, and another, with dementia, was exposed to potential sexual abuse when another cognitively impaired resident attempted to get into bed with them. The facility did not ensure proper communication or assessment of known resident relationships, contributing to these failures.
The facility did not report allegations of injury of unknown origin, verbal abuse, neglect, and drug diversion to the State Survey Agency within the required timeframe. Incidents involving residents with complex medical conditions and a case of drug diversion by an RN were all reported late, contrary to facility policy requiring immediate notification.
The facility did not complete a thorough investigation or submit timely reports for two residents involved in abuse and neglect allegations. One resident's substantiated verbal abuse case was not reported to the State Agency within the required timeframe, and another resident's neglect investigation lacked interviews with other residents present during the incident.
A resident at moderate risk for falls experienced an unwitnessed fall in her room, with a wardrobe/dresser found on top of her. The facility's investigation focused on the wardrobe's position rather than the circumstances leading to the fall, failing to conduct a root cause analysis. The investigation did not determine when the resident was last assisted with toileting or if staff heard her request for help. Additionally, the facility did not ensure that wardrobe dressers were safely secured to prevent similar incidents.
A resident's missing gold necklace was not reported to the NHA or State Survey Agency within 24 hours, delaying the investigation. The family reported the missing item to an LPN, who left a voicemail for the NHA, but the NHA was not informed until days later. The facility's policy requires immediate reporting and investigation, which did not occur due to a communication breakdown.
Two residents in an LTC facility did not receive necessary care to prevent and manage pressure injuries. One resident's care plan was not followed, leading to extended periods in a wheelchair without repositioning, while another resident's air mattress was not functioning, yet staff documented it as checked and working. These deficiencies highlight lapses in adhering to professional standards for pressure injury prevention and management.
Three residents in an LTC facility experienced multiple falls due to inadequate supervision and failure to implement and update fall prevention interventions. One resident suffered a hip fracture and wrist fractures, while another's care plan was not followed, leading to falls. Investigations were incomplete, lacking root cause analysis and necessary care plan revisions.
The facility failed to adhere to professional food safety standards, affecting 65 residents. Observations included improper food storage, expired milk, structural issues in the kitchen, and staff not wearing beard covers. Additionally, improper storage practices were noted with flour bins and unbaked cookie dough. These issues were acknowledged by the kitchen manager and shared with the facility's administration.
The facility failed to maintain effective infection control practices, as shared glucometers were not cleaned between uses, and a resident's catheter bag was left on the floor. LPNs were observed using the same glucometer on multiple residents without proper disinfection, and a resident reported their catheter bag was not attended to in a timely manner, indicating lapses in adherence to infection control protocols.
The facility failed to report allegations of abuse and a physical altercation involving residents within the required timeframe. In one case, a resident's abuse allegation was reported two days late, allowing the alleged perpetrator to continue working. Another incident involved a family altercation in the dining room, reported late to the Nursing Home Administrator. A third resident's abuse claim was also delayed in reporting due to disbelief and lack of physical evidence.
The facility failed to thoroughly investigate abuse allegations for three residents, including incidents of possible retaliation, family altercations, and forced care. Investigations were incomplete, staff education was lacking, and law enforcement was not always notified. The previous NHA dismissed complaints and did not ensure comprehensive investigations or staff training.
The facility failed to complete necessary PASARR screenings for two residents. One resident remained beyond a 30-day exemption without a revised PASARR, and another resident with Schizophrenia was inaccurately screened, missing a required Level II PASARR. Errors by admissions staff and procedural lapses contributed to these deficiencies.
Three residents in the facility did not have comprehensive care plans addressing their specific health needs. One resident on continuous oxygen lacked a respiratory care plan, another with bowel issues had no bowel monitoring plan, and a third with incontinence had no care plan for managing toileting. The Director of Nursing and MDS Coordinator acknowledged these oversights, attributing them to possible oversight and frequent hospitalizations.
A resident with chronic abdominal issues and on multiple bowel medications was not adequately monitored by the facility. Despite the facility's policy requiring regular assessment of continence, there was no documentation of bowel monitoring or a care plan for bowel management. Discrepancies were noted between the resident's ADL care plan and CNA worksheet regarding continence status, and staff interviews revealed inconsistent documentation practices.
A facility failed to comprehensively assess and manage a resident's urinary incontinence, leading to a lack of appropriate treatment and services. Despite the resident's cognitive intactness and documented changes in continence status, no comprehensive assessments or care plans were initiated. Staff interviews revealed a lack of documentation and communication regarding the resident's incontinence care needs, contributing to ongoing issues and risk for complications.
A resident experienced significant weight fluctuations that were not properly identified or addressed by the facility. Despite policies requiring notification of significant weight changes to the dietician and physician, there was no evidence of such notifications. Discrepancies between weights recorded in the EHR and dialysis forms were not questioned, leading to a lack of appropriate nutritional interventions.
A resident with malignant pleural effusion and atrial fibrillation did not receive appropriate respiratory care as their oxygen tubing and humidification were unlabeled and undated, and the humidification water level was inadequate. The resident's oxygen was set at 3L/min, contrary to the physician's order of 2L/min as needed. There was no documentation of the resident's vital signs or a respiratory care plan, and the facility's policy on oxygen administration was not followed.
A facility failed to provide adequate care and monitoring for three residents, leading to significant health declines. One resident, admitted with chronic kidney disease and anemia, did not receive necessary lab work, daily weight monitoring, or a nephrology follow-up, resulting in a severe health decline and death. Another resident with edema had no care plan or monitoring, and a third resident did not have all required stool samples collected or a colonoscopy scheduled.
The facility did not conduct annual performance reviews for CNAs, affecting their ability to assess skills competency and provide necessary training. This deficiency involved five CNAs, with no documented reviews since their hire dates. The DON confirmed the lack of reviews, and the facility had no policy for annual performance reviews, potentially impacting care for all 72 residents.
The facility failed to provide required annual Resident Rights training to several staff members, including dietary staff and CNAs, since their hire dates. Despite having a training schedule that included this as a required topic, there was no documentation to confirm completion. The DON confirmed the lack of training records and the absence of a specific training coordinator, highlighting a gap in oversight. This deficiency had the potential to impact all 72 residents in the facility.
The facility failed to provide mandatory annual QAPI training to several staff members, including a PT, a dietary staff member, an RN, and multiple CNAs. The Director of Nursing confirmed the absence of documented training and acknowledged the lack of a specific training coordinator. This deficiency had the potential to impact all 72 residents in the facility.
The facility failed to provide mandatory Infection Control training to several staff members, including a PT, a Dietary staff member, and multiple CNAs, as required by their Infection Control Program. The DON confirmed the lack of documentation and acknowledged the absence of a specific training coordinator, resulting in the oversight.
The facility failed to provide required annual Compliance and Ethics training to staff, including a PT, DIET, RN, and several CNAs, potentially affecting all 72 residents. The facility lacked a policy for this training, and the 2023 training schedule did not include it. The DON confirmed the absence of training documentation and acknowledged the lack of a specific training coordinator.
The facility failed to provide required annual Behavioral Health training to several staff members, including a PT, DIET, RN, and multiple CNAs. The facility's assessment and training schedule did not include Behavioral Health as a required topic, and the DON confirmed the absence of documented training. Despite being informed of the issue, no additional information was provided to demonstrate compliance.
The facility failed to maintain the confidentiality of resident information, as report sheets and CNA worksheets containing personal details were left unattended in a dining area. These documents included names, physician details, and care requirements, and were observed multiple times without staff present to secure them. The issue was acknowledged by the ADON, but no explanation was provided for the breach.
The facility failed to maintain an effective training program for staff, lacking documentation and formal procedures for required training. Eight staff members, including a PT, DIET, RN, and CNAs, were affected. The DON confirmed the absence of a formal program and training coordinator, and the facility could not provide evidence of completed trainings.
The facility did not ensure that six direct care staff members, including an RN and five CNAs, received communication training as required. The facility's training schedule did not include communication training, and there was no documentation of such training for these staff members since their hire dates. The DON confirmed the absence of training records and the lack of a designated training coordinator.
The facility did not ensure that staff received annual training on Abuse/Neglect/Exploitation and Dementia care. Several staff members, including dietary staff and CNAs, lacked documentation of completing this training. The facility's training schedule included relevant topics, but there was no evidence of completion. The DON confirmed the absence of documentation and a training coordinator.
The facility failed to ensure that five CNAs completed the required annual 12 hours of educational training, including dementia management and abuse prevention. The DON confirmed the lack of documentation and the absence of a training coordinator, potentially affecting resident care.
A resident reported feeling mistreated by a CNA, but the LTC facility delayed reporting the abuse allegation to the State Agency and Nursing Home Administrator. The CNA was not immediately removed from resident contact, and six residents were left unattended, raising concerns of neglect. The facility's policies on timely reporting and safeguarding were not followed.
The facility failed to thoroughly investigate allegations of misappropriation, neglect, and mistreatment involving three residents. One resident reported missing money, but the police were not notified, and other residents were not interviewed. Another resident was found in a soiled gown with no care provided for hours, and the facility did not investigate the lack of care. A third resident reported mistreatment by a CNA, but the investigation lacked thoroughness, with insufficient staff and resident interviews.
A resident with a history of diabetes and moderate cognitive impairment was found to have very long toenails, indicating a lack of proper foot care. The facility staff were unable to provide documentation of recent podiatry visits, despite the resident's need for assistance with footwear and the understanding that the resident's family arranges for podiatry care outside the facility.
Failure to Hold and Document Required Quarterly Care Plan Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were able to participate in the development and implementation of their person-centered plans of care through required quarterly care plan conferences. Facility policy dated 1/5/25 states that care plan review/conference will be conducted at least quarterly, be interdisciplinary, and provide an opportunity for resident and family discussion and input. For one resident admitted with cervical radiculopathy, adult failure to thrive, pulmonary hypertension, and depression, with a BIMS score of 15 indicating intact cognition, there was no documentation of any quarterly care conference from mid-2025 through early 2026. The resident reported that care conferences had been scheduled in April and July but that no one showed up, and that nothing had been scheduled since July. Review of the medical record and progress notes from 6/17/25 to 2/3/26 revealed no evidence of a quarterly care conference, and both the Social Services Designee and Director of Social Services confirmed they could not identify any such conference for this resident. A second resident, admitted with palliative care needs, chronic lymphocytic leukemia, heart failure, and COPD, had a quarterly MDS showing severe cognitive impairment with a BIMS of 7 and functional limitations requiring assistance with mobility, hygiene, eating setup, showering, bed mobility, and transfers. Review of this resident’s progress notes and medical record on 2/3/26 showed no documentation of any care conferences. The social worker responsible for care conferences and admissions stated that no care conferences had been completed for this resident to their knowledge and that they had not conducted any for this resident. The social worker was unable to provide any emails or notes indicating that care conferences had occurred. When interviewed, the resident did not recall any care conferences since admission and stated that family usually handled care discussions but had not mentioned any conferences recently. A third resident, readmitted with Alzheimer’s disease, type II diabetes mellitus, dementia, and anxiety disorder, was described by staff as confused and speaking only a non-English language. Review of this resident’s medical record showed no evidence of any care conference in the previous twelve months while the resident resided full time at the facility. The social worker responsible for care conferences and admissions stated that, to their knowledge, no care conferences had been completed for this resident and confirmed they had not conducted any. They were unable to provide any supporting documentation such as emails or notes about care conferences. When these findings were presented to facility leadership, including the DON, NHA, and Director of Operations, no additional information was provided to explain the absence of required care conferences for these residents.
Failure to Timely Report Resident’s Allegation of Staff Mistreatment
Penalty
Summary
The facility failed to report a resident’s allegation of potential abuse to the State survey agency and the Nursing Home Administrator within the timeframes required by its abuse, neglect, and exploitation policy. The policy, last reviewed on 11/5/25, requires all alleged violations to be reported to the Administrator, State agency, adult protective services, and other required agencies within 2 hours if the allegation involves abuse or serious bodily injury, or within 24 hours if it does not. On 1/1/26 at 6:12 a.m., an RN documented that the resident requested to see the nurse during the night shift and complained about two night-shift CNAs who performed ADL care, stating he wanted the matter reported. The RN notified the DON and obtained CNA statements, but there is no documentation that the allegation was reported to the State agency or the Nursing Home Administrator. The resident involved had diagnoses including cervical radiculopathy, benign prostatic hyperplasia, adult failure to thrive, pulmonary hypertension, and depression, and was cognitively intact with a BIMS score of 15. The MDS documented that the resident was dependent on staff for toileting hygiene and transfers, required substantial/maximal assistance for rolling, and was always incontinent of urine with a colostomy. During an interview with the Surveyor, the resident described an incident on New Year’s Day in which two female staff insisted on changing him despite his statement that he was not wet, and he alleged that one staff member held his wrists and pulled him, hurting his shoulder, while the other removed his brief. He reported telling the nurse that staff had “roughed him up” and that something had to be done, and confirmed he told the nurse that his wrists were held down. The RN later confirmed to the Surveyor that the resident complained about how staff were trying to change him and wanted to make a report, and that this was reported to the DON. The NHA stated she was not notified of the allegation and confirmed there had been no facility-reported incidents to the State agency for this resident in the last six months.
Failure to Thoroughly Investigate Resident Allegation of Rough Care by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of mistreatment as required by its abuse, neglect, and exploitation policy. The policy, last reviewed on 11/5/25, requires an immediate investigation of any suspicion or report of abuse, neglect, or exploitation, including identifying and interviewing all involved persons (alleged victim, alleged perpetrator, witnesses, and others with knowledge) and providing complete documentation. Despite this, the facility did not conduct a comprehensive investigation after a resident reported concerns about how two CNAs provided ADL care, and the facility did not interview any other residents to determine if there were broader concerns about care. The resident involved had diagnoses including cervical radiculopathy, benign prostatic hyperplasia, adult failure to thrive, pulmonary hypertension, and depression, and was cognitively intact with a BIMS score of 15. He was dependent on toileting hygiene and transfers, required substantial/maximal assistance for rolling, was always incontinent of urine, and had a colostomy. On New Year’s Day, he reported to the Surveyor that two female staff entered his room around 2:00 a.m. to change him; he stated he told them he was not wet, but they insisted on changing him, that one staff member held his wrists and pulled him, hurting his shoulder, while the other removed his brief, and that he told them he did not have dementia and did not need this care. He further stated he reported to the nurse that staff had “roughed him up” and held his wrists down, and that the nurse did not respond. A nurse’s note dated 1/1/26 at 06:12 by an RN documented that the resident wanted to see the nurse during the night shift, complained about the two night CNAs who performed ADL care, and wanted the issue reported. The RN notified the DON and was authorized to have the CNAs write statements, which were placed under the DON’s door. In interviews, the RN confirmed he reported the incident to the DON. The DON acknowledged being notified that the resident did not want to be changed and that she had CNA statements, and described the situation as the resident becoming belligerent, striking out at staff, and refusing care. However, the DON stated she did not talk to the resident, did not conduct an investigation, did not interview the CNAs beyond obtaining their written statements, and did not obtain a statement from the RN. The NHA also reported not conducting any investigation. As a result, the facility lacked evidence of a thorough investigation of the resident’s allegation, and no resident interviews were conducted to identify any additional concerns about care.
Failure to Develop Person-Centered Baseline Care Plan on Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered baseline care plan within 48 hours of admission for a newly admitted resident. Facility policy required that a baseline care plan be developed within 48 hours of admission, including minimum healthcare information such as initial goals based on admission orders, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable. The policy also required that the admitting or supervising nurse gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative, then establish goals and interventions reflecting the resident’s stated goals and current needs, and that a supervising nurse verify within 48 hours that a baseline care plan had been developed. For this resident, the baseline care plan that was created did not contain specific, person-centered interventions and did not fully reflect the resident’s identified needs and hospital discharge instructions. The resident was admitted with multiple diagnoses, including a wedge compression fracture of the second thoracic vertebra, bilateral pneumonia, type 2 diabetes mellitus, essential hypertension, chronic heart failure, Alzheimer’s disease, and dementia. The 5-day admission MDS documented a BIMS score of 4, indicating severely impaired decision-making, and showed that the resident required varying levels of assistance with ADLs, was always incontinent of bowel and bladder, was at risk for pressure injuries, and was on a mechanically altered diet. Hospital discharge documentation indicated the resident needed a TLSO brace, a puree/thin diet with no straws, small sips, upright positioning, 1:1 supervision, and medications crushed in puree. Hospital therapy notes documented that the resident was unable to complete self-care and functional mobility sufficient to return to the prior living situation, required alarms for safety, and needed moderate assistance for functional mobility with identified deficits in ADLs, mobility, cognition, safety awareness, and sequencing. Despite these identified needs, the facility’s baseline care plan and CNA Kardex contained generic, incomplete, and non–person-centered interventions. The baseline care plan listed problems such as diabetes, oxygen use, pain, psychotropic medication use, fall risk, potential/actual skin integrity impairment, bowel and bladder incontinence, ADL self-care deficits, limited physical mobility, and a desire to discharge home, but many interventions were left blank or written in non-specific terms (e.g., “specify what assistance,” “specify frequency,” “provide pressure relieving device(s): (specify)”). The care plan did not document the need for 1:1 supervision, the pureed diet with no straws, or other specific hospital discharge instructions. Fall interventions were limited to generic measures such as keeping the call light within reach, educating about safety, and following facility fall protocol, without individualized strategies similar to the hospital’s use of bed and chair alarms. The Kardex, which CNAs relied on for daily care, mirrored these incomplete and non-specific interventions and did not include detailed fall-prevention or aspiration-prevention measures. During interviews, the DON acknowledged that the baseline care plan and Kardex were not specific and that staff would not have known how to care for the resident to keep the resident safe and support the highest level of independence.
Failure to Complete Neurological Checks per Policy After Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete and document neurological assessments according to its own policy and procedure following unwitnessed falls for one resident. The facility’s Neurological Assessment policy, effective 5/19/22, requires neuro checks after head injuries or when indicated for a change in condition, including unwitnessed falls, with assessments of level of consciousness, speech, pupils, hand grasps, and vital signs. Unless otherwise ordered, the policy specifies a schedule of Q15 minutes × 1 hour, Q1 hour × 4 hours, then Q shift × 72 hours. The DON stated that the expectation is 4 fifteen‑minute checks, 4 one‑hour checks, and 4 eight‑hour checks, all documented in the electronic medical record. The resident involved had multiple diagnoses including wedge compression fracture of the second thoracic vertebra, fall history, pneumonia, type 2 DM, essential HTN, chronic heart failure, Alzheimer’s disease, and dementia, and had a BIMS score of 4 indicating severely impaired decision‑making. The resident experienced two unwitnessed falls on the same day, both documented as having no injuries, and the 24‑hour report indicated that neuro checks were initiated after each fall. For the first unwitnessed fall at 4:33 PM, documentation showed 4 fifteen‑minute neuro checks, 2 thirty‑minute checks, and 2 one‑hour checks, with no further checks completed per policy. For the second unwitnessed fall at 8:35 PM, documentation showed 4 fifteen‑minute neuro checks and 1 thirty‑minute check, with no additional checks completed per policy. No explanation was provided as to why the neurological checks were not completed in accordance with the facility’s policy and procedure.
Failure to Provide Adequate Supervision and Person-Centered Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, assistance, and person‑centered fall prevention interventions for residents at high risk for falls, and failure to conduct thorough post‑fall investigations with root cause analyses. One resident was admitted with multiple diagnoses including a history of falls, dementia, Alzheimer’s disease, weakness, impaired mobility, and cognitive deficits. Hospital documentation prior to admission showed this resident required bed and chair alarms and had significant safety‑awareness and functional limitations. On admission, the facility’s fall risk assessment identified the resident as high risk for falls, and PT/OT evaluations documented balance deficits, decreased safety awareness, impaired judgment, and a high risk for further falls without skilled interventions. Despite this, the baseline care plan and Kardex contained generic, incomplete, and non‑person‑centered interventions such as “call light within reach,” “follow facility fall protocol,” and unspecified assistance levels for bed mobility, transfers, ambulation, and ADLs, without clear instructions to staff on how to safely care for the resident. Within approximately 48 hours of admission, this resident experienced three falls. The first two falls on the same day were unwitnessed, and documentation by the LPN noted the resident was found on the floor, assessed as alert and oriented to one, with neuro checks documented and vital signs stable. The resident was assisted back to a wheelchair and placed in common areas for supervision. However, when the surveyor requested the fall investigation for the first unwitnessed fall, the facility could not provide a completed investigation with root cause analysis, and there were no staff statements describing where in the room the resident was found, what the resident had been doing, or other contextual details such as continence status. For the second unwitnessed fall, the facility’s fall investigation form lacked clarity about where the resident had been last seen (bed or chair), how far the resident moved before being found on the floor under a chair, and how the resident sustained a bump to the right side of the head. There were no staff witness statements, and no documented root cause analysis or detailed investigation of contributing factors. The surveyor also noted there was no RN assessment documented after the first fall. The third fall for this resident was a witnessed fall at the nurses’ station, where the resident had been kept under supervision after the earlier events. Nursing documentation described the resident as confused, refusing to sit, fighting and scratching staff, verbally expressing a desire to fall, and pulling out oxygen tubing. The nurse reported that the resident suddenly stood up and fell, sustaining a head laceration that required emergency room evaluation. When the surveyor requested a fall investigation and root cause analysis for this event, the facility again was unable to provide one, and there were no staff statements detailing what specific interventions were attempted to manage the resident’s agitation and maintain safety at the nurses’ station. The DON later acknowledged that there were no person‑centered fall interventions in place for this resident despite the known high fall risk and prior hospital documentation. A second resident, also identified as high risk for falls based on a fall risk assessment, had a care plan that listed only generic interventions such as keeping the call light within reach, ensuring appropriate footwear, and following facility protocol. This resident experienced an unwitnessed fall while getting out of bed. The fall investigation form documented that the resident was found on the floor and that the call light was within reach, but the witness statement indicated, “I didn’t see anything.” The investigation did not include additional staff statements or information about when the resident was last seen or last toileted before the fall. When questioned, the DON confirmed that the facility had no further information regarding the timing of the last observation or toileting. Across both residents, the facility did not complete thorough post‑fall investigations or root cause analyses and did not develop or revise individualized, person‑centered interventions to address identified fall risks.
Failure to Inspect and Document Safety of Beds and Bed Rails per MIFU and FDA Guidance
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document required inspections and safety assessments of resident beds, including bed frames, mattresses, and bed rails or assist/mobility bars. Surveyors observed resident beds with assist/mobility bars in use. During interviews, the Nursing Home Administrator stated there were no bed inspections being conducted and confirmed there was no policy regarding bed inspections. The Maintenance Director reported that when a new admission is anticipated, maintenance staff go to the room, remove safety bars, ensure a mattress is present, inspect the bed, test the remote, and check for exposed wires, and that therapy may later order safety bars or bed extensions or special mattresses. However, the Maintenance Director acknowledged that these inspections are not documented. Review of the Manufacturer’s Instructions for Use (MIFU) for Joerns Model U770, U790, and U795 beds showed that the beds and accessories are to be visually inspected monthly for broken welds, cracks, and loose hardware, and that any bed with such defects must be removed from service and repaired. The facility did not document that these monthly inspections were performed for any of the 77 resident beds. In addition, review of FDA guidance on hospital bed system entrapment risks identified seven potential entrapment zones and recommended dimensional limits for zones 1–4. The Maintenance Director stated that although they have reference sheets describing the seven or eight entrapment zones and related measurements, the facility does not perform or document FDA entrapment safety zone measurements for any of the 36 residents identified as having bed rails, mobility bars, or assist bars.
Failure to Maintain Safe Hot Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to maintain and serve food at safe temperatures in accordance with professional standards and its own food safety policy. A cognitively intact resident with severe protein-calorie malnutrition and multiple comorbidities, including spinal stenosis, history of stroke, COPD, poly-osteoarthritis, and anxiety disorder, reported that the food served was cold and that not all aides would reheat it. During the evening meal observation, the resident consented to have the temperature of her meal checked as it was removed from the transport cart for delivery. The Dietary Manager measured the temperature of the chicken and noodles on the resident’s tray and found it to be 93.7°F as it came off the cart, acknowledging that the last cart had arrived on the floor earlier and that the food was not hot enough. The Dietary Manager stated the need to reheat the food to 165°F. Review of the facility’s Food Safety policy showed that staff are required to monitor food temperatures while holding for delivery and to follow FDA Food Code standards, including reheating cooked and cooled food to 165°F and heating ready-to-eat foods to at least 135°F. Federal guidance cited in the report explains that bacterial growth can occur when food remains in the “Danger Zone” (between 40°F and 140°F/135°F) for too long, and that hot food should be kept at or above 140°F.
Failure to Provide Required Meal Set-Up Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required meal set-up assistance for one resident who needed help with activities of daily living (ADLs). The resident had diagnoses including cerebral infarction, parkinsonism, hemiplegia, and hemiparesis affecting the left non-dominant side, and a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderately impaired cognition. The resident’s quarterly MDS documented a need for assistance with meal setup and cleanup. During a dining room observation, the resident was seated alone with his meal plate still covered in plastic wrap; he had only partially torn the wrap and had not fully removed it, and did not respond when asked if assistance was needed. During the same observation, the Dining Services Manager approached and removed the plastic wrap, stating that the serving staff should have removed it when the meal was served. A CNA later acknowledged that she should have removed the plastic wrap from the resident’s meal tray, although she stated the resident no longer required staff to feed him. The DON stated that CNAs serving meals were required to complete meal setup when indicated, and the Nursing Home Administrator stated that staff were expected to meet all ADL needs, including meal setup and cleanup when indicated. Review of the facility’s ADL policy confirmed that, based on the comprehensive assessment and resident needs, the facility must provide necessary care and services to maintain ADL abilities, including assistance with meal setup.
Failure to Administer Acarbose as Ordered Before Meals
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed medication, acarbose 25 mg, as ordered to a resident with hypoglycemia, diabetes, and diabetic chronic kidney disease. The resident was admitted on 10/17/25 and readmitted on 10/31/25, with an acarbose order dated 11/20/25 for administration by mouth before meals at 7:30 AM, 11:30 AM, and 4:30 PM. Review of the Medication Audit Report for the ordered acarbose doses over multiple days showed repeated late administrations significantly outside the scheduled times, including morning doses given several hours after the ordered time and evening doses given hours late. On one date, two separate scheduled doses (7:30 AM and 11:30 AM) were documented as administered at the same time. The Nursing Home Administrator reported during interview that the facility did not have a policy regarding medication administration. The DON stated the expectation that medications are given as ordered and, upon reviewing the Medication Audit Report, acknowledged that the documented administration times were outside the normal administration leeway and that nurses should document when medications are given outside parameters due to meal delivery time. Reference material from the National Institute for Health indicated that acarbose should be administered three times daily with the first bite of each meal to delay carbohydrate digestion and slow glucose absorption. A message was left with the Medication Technician who worked most of the relevant dates and times, but no return call was received, leaving the late and irregular administration times unexplained.
Failure to Document and Investigate Resident Grievance Regarding Incontinence Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's grievance was formally documented, investigated, and resolved according to the facility's grievance policy. The resident, who was cognitively intact and dependent on staff for mobility and transfers, reported being left on the call light for 4-5 hours while needing incontinence care after their ostomy bag broke, resulting in feces exposure. The resident attempted to get assistance by calling the main facility phone number multiple times, and although several staff responded to the call light, they did not provide the necessary care. The Director of Social Services was notified of the resident's repeated calls and visited the resident's room, but did not initiate a formal grievance or document the concern. The Nursing Home Administrator, who is designated as the facility's grievance official, was aware of the incident but did not gather further details, obtain staff statements, or conduct an investigation. Both the Director of Social Services and the Nursing Home Administrator acknowledged that a formal grievance should have been initiated and investigated, but this was not done. The facility's policy requires that all grievances, including verbal complaints, be documented, investigated, and resolved promptly, with written decisions issued to the resident. In this case, the facility staff did not follow these procedures, resulting in the resident's expressed care concerns not being formally addressed or investigated as required by policy.
Failure to Complete PASARR Screening After 30-Day Exemption Expired
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was accurately screened for a mental disorder prior to the expiration of a 30-day PASARR (Preadmission Screening and Resident Review) exemption. The resident was admitted with diagnoses including anxiety disorder, depression, dementia, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and atherosclerotic heart disease. The resident's initial PASARR Level 1 screening indicated a major mental disorder and documented a 30-day hospital discharge exemption. However, after the 30-day exemption expired, no new PASARR Level 1 screening was completed, despite the resident continuing to reside in the facility for over a year. The facility's policy requires a Level 1 PASARR screen for new admissions and specifies that a new screen is not required only if the attending physician certifies the resident will need less than 30 days of nursing facility services. In this case, the admissions department completed the initial PASARR, but the responsibility for subsequent screenings or referrals was assigned to the social services department. The deficiency was identified when it was discovered that the resident's PASARR was not updated after the exemption period, and there was no documentation explaining why the required screening was not completed.
Failure to Complete Thorough Fall Investigations for High-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including hypertensive encephalopathy, hemiplegia, prostate cancer, chronic pulmonary embolism, anemia, gout, dementia, and depression, was identified as being at high risk for falls. The resident experienced three unwitnessed falls within the facility. Despite the facility's policy requiring thorough post-fall investigations, including root cause analysis and staff statements, these procedures were not consistently followed for each incident. For the first two falls, no Post-Fall Investigation Forms were completed, and there was a lack of documentation regarding what the resident was doing prior to the falls, what interventions were in place, and whether those interventions were effective. The third fall had a Post-Fall Investigation Form completed, but it lacked staff statements and did not provide input on interventions to prevent further falls. The absence of thorough investigations prevented the identification of root causes and the implementation of effective fall prevention strategies. Interviews with the DON revealed that prior to their tenure, thorough investigations were not being completed, and although new policies and training were implemented, the required investigative steps were still not followed for these incidents. The facility was unable to provide explanations for the lack of comprehensive investigations for the resident's three falls, resulting in a failure to ensure adequate supervision and accident prevention as required by facility policy.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding significant weight loss. The resident, who had multiple diagnoses including severe protein calorie malnutrition, chronic kidney disease, and legal blindness, experienced a weight loss of 10.1 pounds (6.61%) over three weeks. Despite facility policy requiring notification of the physician or registered dietician (RD) for significant weight changes, there was no evidence that either was notified or that new nutritional interventions were implemented. The resident's care plan identified them as at risk for impaired nutrition, and assessments indicated malnutrition and ongoing weight concerns, but no follow-up documentation or recommendations from the RD were found after the initial assessment. Additionally, the facility failed to maintain adequate documentation of the resident's meal intake, with over half of the meals served lacking any record of consumption. This lack of documentation made it impossible to accurately assess the resident's nutritional intake in relation to the observed weight loss. The surveyor confirmed these findings with facility leadership, who acknowledged the gaps in documentation and monitoring but did not provide further information prior to the survey exit.
Failure to Timely Report Alleged Abuse to Proper Authorities
Penalty
Summary
A deficiency occurred when staff failed to report an allegation of inappropriate touching between residents in a timely manner, as required by facility policy. A resident with intact cognition reported to a physical therapist that another resident had put a hand inside their shorts during lunch. The physical therapist documented the incident on a Stop and Watch form and notified the unit nurse. However, the nurse did not escalate the report to the Nursing Home Administrator (NHA) or other appropriate authorities, instead speaking with the resident and concluding that no further action was needed after the resident denied the incident. This resulted in a delay of at least twelve hours before the NHA was notified and the incident was reported to the state agency. Facility policy required immediate reporting of abuse allegations, but staff failed to follow this protocol. The NHA and Director of Clinical Services confirmed that the Stop and Watch form was not the appropriate method for reporting abuse and that the nurse should have reported the incident immediately. The delay in reporting was attributed to the nurse's decision not to escalate the matter, despite being made aware of the allegation by the physical therapist.
Failure to Provide Necessary Behavioral Health Services After Inappropriate Resident Behavior
Penalty
Summary
The facility failed to ensure that a resident with dementia and depression received necessary behavioral health care and services as required by their comprehensive assessment and care plan. The resident, who had a severe cognitive impairment and a history of depression, exhibited inappropriate sexual behavior towards another resident. Despite this incident being reported to staff and documented, there was no evidence that the psychiatric provider overseeing the resident's care was notified of the behavior. Additionally, there was no documentation that the resident received medically related social services to address or debrief the behavior following the incident. Further review revealed that the facility did not initiate or update a care plan to address the resident's depression or the manifestations of their mental health condition. The psychiatric provider was not kept informed of the resident's behaviors, and there was no documentation that the resident's Power of Attorney was contacted to obtain consent for continued psychiatric services. The lack of communication and documentation resulted in the resident not receiving appropriate behavioral health interventions or follow-up after the incident.
Failure to Protect Resident Property and Prevent Drug Diversion
Penalty
Summary
The facility failed to prevent the misappropriation of resident property for five sampled residents, resulting in missing cash and personal items such as wallets, credit cards, and identification cards. An audit of valuable envelopes stored in the Social Services Director's (SSD) office revealed that several residents were missing various amounts of money, and there was no documentation of reimbursement for the missing funds or for the replacement of a resident's driver's license. The SSD stated that valuables should be kept in a locked box in the medication room, managed by nursing staff, but the missing items were found to have been stored in the SSD office, indicating a lapse in the facility's process for securing resident property. Additionally, the facility failed to ensure the security of controlled substances, resulting in drug diversion by a registered nurse (RN). Video footage showed the RN removing drugs from the narcotic destruction box using a coat hanger and placing the pills in her pockets. The nurse was an agency staff member whose background check was not on file with the facility, and it was later discovered that her nursing license had been suspended due to previous incidents involving theft and drug diversion at other facilities. The facility's contract with the staffing agency required background checks, but there was no evidence that this was completed for the RN in question. The facility's policies required audits of narcotics, secure storage of controlled substances, and background checks for staff with access to medications. However, these procedures were not consistently followed, as evidenced by the lack of a background check for the RN and the ability to access and remove drugs from the destruction box. The failure to follow established protocols led to the loss of resident property and the diversion of narcotic medications.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify the representative of a resident who experienced a fall, as required by facility policy. The policy, revised in February 2022, states that the resident, their health care provider, and representative must be promptly notified of any changes in the resident's condition or status, including accidents or incidents resulting in injury. In this case, a resident with severe cognitive impairment and multiple diagnoses, including diabetes mellitus, hyperlipidemia, thyroid disorder, osteoporosis, hip fracture, and seizure disorder, experienced an unwitnessed fall. The resident was found on the floor, alert and giggling, but unable to recall how the fall occurred. Upon review, there was no documentation found to confirm that the resident's representative was notified of the fall. Interviews with the Administrator, DON, and Medical Records confirmed that notification to the representative could not be located. The Administrator stated that it was her expectation that family representatives, case workers, and physicians be notified of any falls, but in this instance, there was no evidence that such notification occurred.
Failure to Protect Residents from Verbal and Potential Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and potential abuse. In the first instance, a resident with a history of polyneuropathy, rheumatoid arthritis, depression, and anxiety, and who was cognitively intact, reported being verbally abused by a CNA. The resident stated that after spilling food in the dining room, the CNA hit her hand and yelled at her, later telling her, 'I'll be watching you,' which made the resident fearful. Staff interviews confirmed that the CNA yelled at the resident, though no one witnessed physical contact. The CNA had a history of confrontational behavior and had been previously counseled. In the second instance, a resident with dementia and impaired decision-making was not protected from potential sexual abuse by another resident with moderate cognitive impairment. The incident involved one resident attempting to get into bed with the other, resulting in a fall. The investigation revealed that the two residents had a known friendship, but there was no documentation that the interdisciplinary team had been informed or that assessments and interventions were initiated prior to the incident. The lack of proactive measures contributed to the failure to protect the resident from potential abuse.
Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, and injury of unknown origin to the State Survey Agency (SSA) as required by its own policy, which mandates immediate reporting but not later than two hours. Specifically, an incident involving a resident with Alzheimer's, congestive heart failure, and chronic kidney disease who sustained skin tears to her right hand was not reported to the SSA until over a month after the event. Another case involved a resident with polyneuropathy, rheumatoid arthritis, depression, and anxiety who reported verbal abuse by a CNA, but the incident was not reported to the SSA until a week later. Additionally, a resident with a femur fracture, right knee contracture, and lymphedema experienced neglect when care was not provided, and this was not reported to the SSA until several days after the incident. The report also documents an incident of misappropriation of property involving drug diversion by an RN, which was discovered via video surveillance and reported to the SSA the following day. During an interview, the facility administrator confirmed that the expectation is for immediate reporting of abuse, neglect, and injuries of unknown origin, with investigations to be completed within five days or updates provided to the SSA if not complete. The documented delays in reporting these incidents represent a failure to comply with both facility policy and regulatory requirements.
Failure to Complete Abuse and Neglect Investigations and Timely Reporting
Penalty
Summary
The facility failed to ensure a thorough investigation and timely reporting of alleged abuse and neglect involving two residents. For one resident with diagnoses including polyneuropathy, rheumatoid arthritis, depression, and anxiety, the facility did not submit the required five-day report to the State Agency detailing the outcome of a substantiated verbal abuse incident by a Certified Nursing Assistant. This omission was identified through a review of the Facility Related Incident documentation and the facility's own policy, which mandates timely reporting of such incidents. For another resident admitted with a femur fracture, knee contracture, and lymphedema, the facility did not complete a comprehensive investigation into an allegation of neglect. Specifically, the investigation failed to include interviews with other residents present during the night in question, as required by facility policy. The Administrator confirmed that the expectation is for a complete investigation, including interviews and record review, but this was not carried out in this case.
Failure to Investigate Fall and Secure Furniture
Penalty
Summary
The facility failed to thoroughly investigate and identify the root cause of a fall involving a resident, who was at moderate risk for falls. The resident experienced an unwitnessed fall in her room, where she was found with a wardrobe/dresser on top of her. The resident reported losing her balance while attempting to go to the bathroom after calling for help and receiving no response. The facility's investigation focused primarily on the wardrobe's position rather than the circumstances leading to the fall. The facility's falls policy requires a comprehensive evaluation of the area where a fall occurred to identify potential contributors. However, the investigation did not include a root cause analysis of why the resident attempted to toilet herself after requesting assistance. The investigation also failed to determine when the resident was last assisted with toileting or if staff heard her request for help. Additionally, there were conflicting statements from staff regarding the resident's seating position before the fall, which was not resolved in the investigation. The facility did not ensure that the wardrobe dressers used by residents were safely secured to prevent similar incidents. The investigation did not include checking the condition of other dressers/wardrobes in resident rooms, despite the potential safety concern. The facility's focus on whether the dresser had fallen on the resident detracted from addressing the actual fall's cause and ensuring the safety of other residents with similar furniture.
Failure to Timely Report and Investigate Missing Resident Property
Penalty
Summary
The facility failed to report a potential misappropriation of property involving a resident's missing gold necklace to the State Survey Agency or the Nursing Home Administrator (NHA) within the required 24-hour timeframe. The incident was initially reported by the resident's family to a facility staff member on November 29, 2024, but the NHA was not informed until December 2, 2024. Consequently, the investigation into the missing necklace did not commence until December 2, 2024, which was a delay from the initial report date. The facility's policy mandates that all reports of misappropriation of resident property should be promptly reported and thoroughly investigated. However, in this case, the Licensed Practical Nurse (LPN) who received the report from the family left a voicemail for the NHA and a note for the social worker, but the NHA did not receive this information in a timely manner. The Executive Director confirmed that the facility's procedure requires immediate reporting and investigation, which did not occur in this instance. The delay was attributed to a communication breakdown, possibly due to the presence of agency staff, as noted by the NHA.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and promote healing for two residents, R5 and R48. R5, who has a history of a sacral stage 4 pressure injury, was noted to have a new area of concern on 4/16/2024, which was not comprehensively assessed or addressed in the care plan until two days later. Despite being assessed as high risk for pressure injuries, R5's care plan was not followed, as observed by the surveyor on multiple occasions, with R5 remaining in a Broda wheelchair for extended periods instead of being repositioned or laid down as required for pressure injury healing. R48, who was assessed as a moderate risk for pressure injury development, was observed with a non-functioning air mattress on multiple occasions. The air mattress, intended to reduce pressure and prevent pressure injuries, was not plugged in properly, yet staff were initialing that it was checked and functioning correctly every shift. This oversight indicates a failure to ensure that R48 received the necessary treatment and services consistent with professional standards of practice. The facility's policy on pressure injury assessment and treatment emphasizes the importance of consistent identification and care of pressure injuries, yet the facility did not adhere to these guidelines. The lack of timely assessment and care plan revisions for R5, along with the failure to ensure R48's air mattress was functioning, demonstrate significant lapses in care that could contribute to the development and worsening of pressure injuries.
Inadequate Fall Prevention and Investigation in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent falls for three residents, leading to multiple incidents of falls and injuries. Resident R38 experienced several falls, including one that resulted in a hip fracture and another that led to wrist fractures. The facility did not conduct thorough investigations to determine the root causes of these falls, and the care plan was not consistently updated with appropriate interventions. Despite having severe cognitive impairment, R38 was repeatedly reeducated on call light use, which was not a suitable intervention. Resident R29 also experienced falls due to inadequate implementation of fall prevention interventions. The resident's care plan required the wheelchair to be placed next to the bed to facilitate safe transfers, but this was not followed, leading to falls. The facility acknowledged the oversight but did not provide further information on corrective measures. Resident R43 had a fall that was not thoroughly investigated, with missing details on staff interactions and potential causes. The fall investigation lacked information on when the resident was last checked or toileted, and the care plan was not revised to address the fall's root cause. The facility's failure to conduct comprehensive investigations and update care plans contributed to the ongoing risk of falls for these residents.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, potentially affecting 65 of the 66 residents. During a walkthrough of the kitchen, several deficiencies were observed, including food being stored improperly in the freezer with boxes on the floor and food items like hamburger patties and shredded cheese exposed to air. Additionally, milk cartons in the refrigerator were found to be past their expiration date. The kitchen manager acknowledged these issues and took immediate action to discard the expired and improperly stored items. Furthermore, the kitchen had structural issues, such as large openings in the ceiling covered with plastic, which allowed air to blow over the prep tables, and a leaking dishwasher that caused standing water on the floor, making it slippery and difficult to operate. The surveyor also noted that male kitchen staff members with beards were not wearing beard covers, which is a violation of food safety standards. In the storage area, a scoop was found inside a flour bin instead of being hung on the provided hook, and a bowl was found in another flour bin, indicating improper storage practices. Unbaked cookie dough was also found open to the air in the freezer. These observations were shared with the facility's executive director and nursing administration, but no additional information was provided to explain why the facility did not adhere to professional standards for food service safety.
Infection Control Deficiencies in Glucometer and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling and cleaning of shared glucometers and catheter bags. Observations revealed that the shared glucometer on Medication Carts A & D was not cleaned between resident uses. Licensed Practical Nurse (LPN)-P was observed using the glucometer on multiple residents without disinfecting it between uses, contrary to the facility's policy which requires cleaning and disinfecting reusable equipment between uses. LPN-P admitted to only cleaning the glucometer at the start of the day, not between each resident. Similarly, LPN-Q was observed using the same glucometer on multiple residents, cleaning it only with an alcohol wipe for 15 seconds, which does not meet the required disinfection standards. Additionally, the facility failed to maintain proper catheter care for a resident, R48, who had a suprapubic catheter. The resident's catheter bag was observed lying on the floor, which is against the facility's policy that mandates catheter bags be kept off the floor to prevent infections. The resident, who had intact cognition, reported that the catheter bag was left on the floor until they were assisted into a wheelchair before the noon meal, indicating a lack of timely intervention by the staff. These deficiencies highlight lapses in the facility's infection control practices, particularly in the cleaning of shared medical equipment and the handling of catheter bags. The observations and interviews with staff and residents indicate a failure to adhere to established protocols, potentially compromising the safety and comfort of the residents.
Failure to Timely Report Allegations of Abuse and Altercations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft involving three residents within the required timeframe to the State Survey Agency, Nursing Home Administrator, or local law enforcement. In the case of one resident, an allegation of abuse was not reported to the Nursing Home Administrator until two days after the incident, during which time the alleged perpetrator continued to work at the facility. Law enforcement was not contacted regarding this potential abuse allegation, which involved a certified nursing assistant allegedly retaliating against the resident. Another incident involved a physical altercation between family members of a resident in the facility's main dining room. Although local law enforcement was notified and removed one of the individuals involved, the Nursing Home Administrator was not informed until two days later, delaying the report to the State Agency. The Director of Quality Management, who was informed of the incident, did not report it further, believing it unnecessary as no residents were directly involved or harmed. A third resident reported an abuse allegation, claiming to have been held down and changed against their will. This allegation was reported to the Nursing Home Administrator two days after the incident, and subsequently to the State Agency. The delay in reporting was attributed to the belief that the resident frequently complained and that there was no physical evidence of abuse. The facility's failure to adhere to its own policies and regulatory requirements for timely reporting of such incidents was evident in these cases.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation of resident property for three residents. One resident, with a history of Alzheimer's disease and other medical conditions, reported an incident of possible retaliation by a CNA. The CNA continued to work with residents, including the complainant, during the investigation, and law enforcement was not notified. The facility did not provide education to staff regarding the incident, and the investigation was not conducted in accordance with the facility's abuse prevention policy. Another incident involved a resident's family members engaging in a verbal and physical altercation in the dining room. Although law enforcement was contacted, the facility did not interview all staff with knowledge of the incident. The previous NHA did not ensure that staff were educated on abuse prevention and reporting protocols, and the investigation was not comprehensive. A third resident reported being held down and changed against their will, resulting in shoulder pain and a suspected rotator cuff tear. The facility's investigation was incomplete, with only a few staff statements obtained, and not all staff who may have had contact with the resident were interviewed. The previous NHA dismissed the resident's complaint, citing prejudice and a lack of physical evidence, and did not conduct a thorough investigation or provide staff training on abuse reporting.
Failure to Complete Required PASARR Screenings
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for two residents, R4 and R52, who were reviewed for PASARR screening. R4 was initially admitted with a Level I PASARR indicating a stay of less than 30 days, but remained in the facility beyond this period without a revised Level I PASARR or a Level II PASARR being completed. Upon readmission from the community, R4's medical record lacked a new Level I PASARR despite having diagnoses of depression and anxiety and being prescribed psychotropic medications. R52 was admitted with diagnoses of Schizophrenia and Dementia and was receiving psychotropic medications. However, the PASARR Level I screen inaccurately indicated that R52 was not suspected of having a serious mental illness, resulting in the absence of a necessary Level II PASARR. Admission Director-K acknowledged the error in checking the wrong box on the PASARR Level I screen, which led to the oversight. The facility's policy required a Level I PASARR for new admissions and a Level II PASARR if a serious mental illness or developmental disability was suspected. The failure to complete the necessary PASARR screenings for R4 and R52 was attributed to procedural lapses and errors by the admissions staff, as well as a lack of follow-up when the initial 30-day exemption period for R4 expired.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that three residents had individualized comprehensive care plans addressing their specific health needs. Resident 48, who was readmitted with diagnoses including malignant pleural effusion and atrial fibrillation, was on continuous oxygen as documented in their significant change MDS assessment. However, no care plan was initiated for their respiratory or oxygen needs. The Director of Nursing acknowledged that a care plan should have been initiated, but it was overlooked by the Interdisciplinary Team or nursing staff. Resident 55, admitted with multiple diagnoses including chronic pain and major depressive disorder, was observed to have issues with bowel management, as reported by the resident themselves. Despite receiving several medications for bowel issues, there was no care plan in place for bowel monitoring. The Director of Nursing confirmed that a care plan should have been initiated due to the resident's bowel concerns, but it was not done, possibly due to oversight. Resident 57, with diagnoses including chronic kidney disease and congestive heart failure, was documented as frequently incontinent of bladder and bowel. Despite the Urinary Care Area Assessment indicating the need for a care plan to manage incontinence and associated risks, no such plan was initiated. The resident expressed dissatisfaction with the current incontinence care schedule, and staff confirmed that there was no written care plan or care card detailing the required care frequency. The MDS Coordinator suggested that the resident's frequent hospitalizations might have contributed to the lack of a care plan.
Inadequate Monitoring of Bowel Regimen for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R55, received treatment and care in accordance with professional standards of practice. R55, who has a history of chronic pain, abdominal pain, cognitive communication deficit, major depressive disorder, alcoholic cirrhosis of the liver, and a history of infectious and parasitic disease, was experiencing issues with constipation and diarrhea. Despite being on several bowel medications, the facility did not adequately assess or monitor R55's bowel regimen. The facility's policy required resident continence to be assessed on admission, with significant changes, and quarterly, but there was no indication that staff were monitoring R55's bowel movements or the effectiveness of the scheduled and as-needed medications. The surveyor observed that R55 was self-propelling in a wheelchair and expressed ongoing issues with abdominal pain and bowel movements. The medical record review revealed that R55 was on multiple medications for bowel management, but there was no documentation of bowel monitoring or a care plan for bowel management. Additionally, there was a discrepancy between R55's ADL care plan and the CNA worksheet regarding R55's continence status. Interviews with staff, including RN-G, indicated that while staff asked R55 about bowel movements, there was no consistent documentation in the medical record. The surveyor shared these concerns with the executive director and nursing home administrator, highlighting the lack of consistent monitoring and documentation for R55's bowel regimen and abdominal concerns.
Failure to Assess and Manage Incontinence in a Resident
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence was comprehensively assessed and provided with appropriate treatment and services to prevent complications and restore continence. The resident, who was admitted with diagnoses including chronic kidney disease, congestive heart failure, diabetes, morbid obesity, and anemia, was frequently incontinent of bladder and continent of bowel upon admission. Despite being cognitively intact, no comprehensive bowel or bladder assessments were completed, and no care plan was initiated to provide incontinence care on a scheduled basis. Throughout the resident's stay, multiple Minimum Data Set (MDS) assessments documented changes in the resident's continence status, including increased urinary incontinence and eventual bowel incontinence. However, no revisions were made to the resident's Activities of Daily Living (ADL) Care Plan to address these changes. The facility's policy required periodic assessments and the development of a toileting plan, but these were not implemented. The resident experienced a Stage 3 pressure injury, which healed during a hospital stay, but the facility did not revise the incontinence care plan upon the resident's return. Interviews with staff revealed a lack of documentation and communication regarding the resident's incontinence care needs. Certified Nursing Assistants (CNAs) were aware of the resident's incontinence but did not have a written schedule for care. The MDS Coordinator and interim Assistant Director of Nursing (ADON) were unable to provide documentation of a comprehensive incontinence assessment or a care plan. The facility's failure to conduct thorough assessments and implement a care plan contributed to the resident's ongoing incontinence issues and risk for complications.
Failure to Address Significant Weight Changes in Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R40, maintained acceptable parameters of nutritional status, as evidenced by significant weight fluctuations that were not properly identified or addressed. R40, who was admitted with multiple diagnoses including encephalopathy, end-stage renal disease, and type 2 diabetes, experienced notable weight changes over several months. Despite the facility's policy requiring notification of significant weight changes to the dietician and physician, there was no evidence that such notifications occurred for R40's weight loss and gain. The facility's policy on weight monitoring mandates that significant weight changes be identified and discussed in weekly interdisciplinary team meetings, with recommendations from the registered dietician to be implemented by nursing staff. However, R40's medical records showed discrepancies between weights recorded in the electronic health record (EHR) and those documented on dialysis communication forms. These discrepancies were not questioned or addressed by the facility staff, leading to a lack of appropriate nutritional interventions for R40. Interviews with the registered dietician revealed that the dietician was not consistently notified of R40's significant weight changes, and there was a lack of coordination between the facility and the dialysis provider. The facility's executive director acknowledged the belief that the weights entered were incorrect, yet there was no documentation to support that staff questioned these entries. This oversight resulted in the failure to maintain R40's nutritional status within acceptable parameters.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R48, who was reviewed for respiratory care. The deficiency was observed when R48's oxygen tubing and humidification were not labeled and dated, and the humidification water level was below the tubing, preventing effective humidification. Additionally, R48's oxygen was set at 3 liters per minute, contrary to the physician's order of 2 liters per minute as needed to maintain oxygen saturation above 90%. There were no documented orders for the care of oxygen supplies, and the facility's policy on oxygen administration was not followed. The surveyor noted that R48 was readmitted with diagnoses including malignant pleural effusion and atrial fibrillation, requiring total assistance with activities of daily living. Despite the physician's order for oxygen administration, there was no documentation of R48's vital signs or the need for continuous oxygen at 3 liters per minute. The facility's director of nursing acknowledged the oversight, indicating that the third shift should change and label the tubing and humidification, but this was not reflected in the medication/treatment administration records. The surveyor also found no respiratory/oxygen care plan in place for R48, and the assistant director of nursing, executive director, and nursing home administrator were informed of these concerns.
Failure to Provide Adequate Care and Monitoring
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents, leading to significant health declines and, in one case, death. Resident R4 was admitted with multiple health issues, including chronic kidney disease and anemia. The facility did not complete necessary lab work upon admission, failed to monitor R4's edema with daily weights, and did not arrange a follow-up nephrology appointment. These oversights resulted in R4 experiencing a severe health decline, becoming unresponsive, and ultimately passing away after being transferred to the hospital with multiple organ failure. Resident R1, who was admitted with a right femur fracture, dementia, and anxiety, had lab orders related to bilateral lower extremity edema. However, the facility did not monitor R1's edema, and no care plan was implemented to address this condition. Observations noted that R1's legs were not elevated while sitting in a wheelchair, which could have contributed to the edema. Resident R3, diagnosed with hypertension, atrial fibrillation, and diabetes mellitus, was ordered to have three stool samples collected for occult blood testing. Only one sample was obtained, and there was no documentation of a scheduled colonoscopy, which was necessary for further assessment. The lack of follow-through on these medical orders indicates a failure in the facility's processes to ensure residents receive appropriate care and monitoring.
Removal Plan
- Designee will do a facility-wide lab audit to identify any Residents who had lab orders that did not receive the proper follow up.
- Residents identified will have lab order results verified with the provider and appropriate action taken.
- Designee will audit all lab orders to ensure that labs are completed and are completed to the provider.
- Audit results will be reviewed at the QA committee until the QA committee has determined that substantial compliance has been achieved.
- Direct care licensed nurses will be re-educated on the proper procedures for placing lab orders, ensuring that the lab draws occur per provider's orders and that lab results are reported to the providers in a timely manner.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, which are required to assess their skills competency and provide necessary in-service education. This deficiency was identified for five CNAs (CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W) whose records were reviewed. The facility was unable to provide documentation of any performance reviews conducted since their respective dates of hire, which ranged from 2017 to 2023. This lack of performance reviews meant that the facility could not determine areas of weakness or special needs of residents that might require additional training. The Director of Nursing (DON) confirmed the absence of documented performance reviews for the CNAs in question. The facility also lacked a policy and procedure regarding annual performance reviews, which are necessary to ensure the continuing competence of nurse aides. The facility's 2023 training schedule indicated that all annual education, including performance reviews, should be completed by the end of the year. However, the facility did not adhere to this schedule, potentially affecting the quality of care provided to all 72 residents, as staff assignments float throughout the facility.
Deficiency in Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that staff members received the required annual training on Resident Rights, which is crucial for the proper care of residents. This deficiency was identified during a survey where it was found that several staff members, including dietary staff and certified nursing assistants (CNAs), had not received any Resident Rights training since their hire dates. The facility's training schedule included Protecting Resident Rights in Nursing Facilities as a required training, yet there was no documentation to confirm that this training had been completed for the staff members in question. The Director of Nursing (DON) confirmed the lack of documentation for the training and acknowledged the absence of a specific education or training coordinator, implying a gap in the facility's training oversight. Despite the facility's assessment indicating that staff receive education through various means, including new hire orientation and in-services, the surveyor's review of employee records revealed that the required training had not been provided. This oversight had the potential to affect all 72 residents in the facility, as staff were not adequately trained on the rights of residents and the responsibilities of the facility.
Lack of QAPI Training for Facility Staff
Penalty
Summary
The facility failed to ensure that staff received the mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through staff interviews and record reviews, which revealed that several staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and multiple Certified Nursing Assistants, had not received any QAPI training since their hire dates. The facility was unable to provide a policy or procedure regarding QAPI training, and the 2023 MyLearning-Required Annual Training Assignment Schedule did not include QAPI as a required training topic. The Director of Nursing (DON) confirmed the lack of documented QAPI training for the identified staff members and acknowledged the absence of a specific education or training coordinator, indicating that the responsibility fell to the DON. Despite being asked to provide documentation of QAPI training, the facility was unable to produce any evidence that the training had been conducted for the staff in question. This oversight had the potential to affect all 72 residents in the facility, as the staff were not adequately trained in the QAPI program.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure that all employed staff received annual training on the written policies and procedures of the facility's Infection Control Program. This deficiency was identified through staff interviews and record reviews, which revealed that several employees, including a Physical Therapist, a Dietary staff member, and multiple Certified Nursing Assistants, did not receive the required Infection Control training since their hire dates. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule indicated that Infection Control and Prevention training should have been completed by all staff by a specified due date, but the facility was unable to provide documentation of such training for the mentioned employees. The Director of Nursing (DON) confirmed the lack of documented Infection Control training for the specified staff members and acknowledged the absence of a specific education/training coordinator, implying that the DON was responsible for this oversight. Despite being asked to provide evidence of training, the DON admitted that no documentation was available. The Nursing Home Administrator and the DON were informed of the concern, but the facility did not provide any additional information regarding why the required training was not conducted.
Lack of Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that staff received the required annual Compliance and Ethics training, which had the potential to affect all 72 residents. The surveyor's investigation revealed that the facility did not have a policy or procedure in place for Compliance and Ethics training. Additionally, the facility's 2023 MyLearning-Required Annual Training Assignment Schedule did not include Compliance and Ethics as a required training topic. The facility assessment, last reviewed and updated on 12/28/23, also did not document Compliance and Ethics training as required. Upon reviewing employee records, the surveyor found no documentation of Compliance and Ethics training for several staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and multiple Certified Nursing Assistants. The Director of Nursing confirmed the lack of documentation and acknowledged the absence of a specific education or training coordinator, indicating that they were responsible for training oversight. Despite being informed of the deficiency, the facility did not provide any additional information or documentation to demonstrate that the required training had been completed.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that staff received the required annual Behavioral Health training, as determined by a facility assessment. This deficiency was identified through staff interviews and record reviews, which revealed that several staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and multiple Certified Nursing Assistants, had not received any Behavioral Health training since their hire dates. The facility was unable to provide a policy or procedure regarding Behavioral Health training, and the 2023 MyLearning-Required Annual Training Assignment Schedule did not include Behavioral Health as a required training topic. The facility's assessment, last reviewed and updated in December 2023, did not document Behavioral Health training as a required component under staff training, education, and competencies. The Director of Nursing confirmed the lack of documented Behavioral Health training for the identified staff members and acknowledged the absence of a specific education or training coordinator. Despite being informed of the concern, the facility did not provide any additional information or documentation to demonstrate that the required training had been completed.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal health information for nine residents. On multiple occasions, surveyors observed report sheets and CNA worksheets containing personal information left unattended on a round table in the dining area of the D unit. These documents included residents' names, physician names, and personal care requirements, such as cognition, behavior, mobility, and dietary instructions. The unattended documents were observed at various times throughout the day, with no staff present in the area to secure them. The surveyor confirmed with the Assistant Director of Nursing that such documents should not be left unattended. Despite being informed of the situation, no explanation was provided as to why the personal information was left exposed. The Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing were made aware of the observations, but the report does not mention any immediate corrective actions taken to address the issue.
Lack of Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all facility and contracted staff, as evidenced by the lack of documentation and formal procedures for required training. The deficiency was identified for eight staff members, including a Physical Therapist, a Dietary staff member, a Registered Nurse, and several Certified Nursing Assistants. The facility's assessment, last updated on December 28, 2023, mentioned that staff receive education through new hire orientation, online learning, and in-services, with additional training provided as needed. However, the assessment did not document that all required trainings were provided. During the survey, the facility was unable to provide a policy and procedure regarding the required trainings, nor could they produce documentation that the staff members had completed the necessary trainings since their hire dates. The Director of Nursing confirmed the absence of a formal training program and acknowledged the lack of a specific education or training coordinator, indicating that they were informally responsible for training oversight. Despite being informed of the deficiency, the facility did not provide additional information or evidence of maintaining records of staff training.
Lack of Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that six direct care staff members received communication training, as required by their own training schedule. The staff members in question, including one RN and five CNAs, were randomly selected and found to have no documentation of having completed communication training since their respective hire dates. The facility's 2023 MyLearning-Required Annual Training Assignment Schedule did not list communication training as a required component, and the facility was unable to provide a policy or procedure regarding communication training. The Director of Nursing (DON) confirmed the absence of documented communication training for the staff members and acknowledged the lack of a specific education or training coordinator, implying that the responsibility fell to the DON. Despite the facility's assessment indicating that staff receive education through various means, including new hire orientation and in-services, there was no evidence that the six staff members had received the necessary communication training. This deficiency has the potential to impact the residents on the units where these staff members are typically assigned.
Lack of Required Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that staff received the required annual training on Abuse/Neglect/Exploitation and Dementia care. This deficiency was identified through staff interviews and record reviews, which revealed that several staff members, including dietary staff and certified nursing assistants (CNAs), did not have documented evidence of completing this mandatory training. The facility's training schedule included topics such as understanding Alzheimer's Disease and preventing, recognizing, and reporting abuse, but there was no documentation to confirm that these trainings were completed by the staff in question. The facility was unable to provide a policy or procedure regarding the required training, and the facility assessment did not list Dementia as a training topic. The Director of Nursing (DON) confirmed the lack of documentation for the training and acknowledged the absence of a specific education or training coordinator. Despite the surveyor's request for additional information, the facility did not provide any further evidence to demonstrate that the necessary training had been conducted for the identified staff members.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) completed the required annual 12 hours of educational training. This deficiency was identified through a review of employee records and staff interviews, which revealed that CNAs identified as CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W did not receive the mandated training. The facility was unable to provide documentation to confirm that these CNAs had completed the necessary training hours, which include dementia management and resident abuse prevention training. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged the absence of a specific education or training coordinator, indicating that the responsibility fell to them. Despite being asked to provide evidence of the training, the DON admitted that no such records existed. This oversight has the potential to impact the care of 8-10 residents on each unit where these CNAs are typically assigned, as the training is essential for maintaining the competence of nurse aides.
Delayed Reporting of Abuse Allegation and Inadequate Resident Safeguarding
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R5, in a timely manner to the Nursing Home Administrator and the State Survey Agency. R5 reported an incident involving a Certified Nursing Assistant (CNA-M) on 4/19/24, but the facility did not notify the State Survey Agency until 4/22/24. The Nursing Home Administrator was also not informed until 4/22/24. This delay in reporting violated the facility's policy, which requires immediate reporting of abuse allegations within specified timeframes. R5, who is cognitively intact and requires assistance with daily activities, reported feeling disrespected and mistreated by CNA-M's behavior. Despite the allegation being made known at 6:40 PM on 4/19/24, CNA-M was allowed to remain in contact with R5 and other residents until leaving due to an emergency. This failure to immediately safeguard residents and remove the alleged perpetrator from contact with residents is a significant concern. The facility's Quality Management Director (QMD-E) acknowledged the delay in reporting and the failure to remove CNA-M from resident contact. The Nursing Home Administrator, who was new to the facility, did not complete the investigation and was unable to explain the delay. The surveyor noted that leaving six residents unattended could constitute neglect, yet no self-report or investigation was initiated for this issue.
Inadequate Investigation of Resident Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation, neglect, and mistreatment involving three residents. In the case of one resident, R6, who reported $20 missing, the facility did not notify the police despite the resident's initial indication of wanting police involvement. Additionally, the facility did not interview other residents to determine if there were other instances of missing money. The Nursing Home Administrator (NHA) assumed that the investigation was complete and did not see the need to interview other residents unless deemed necessary. Another incident involved R3, who was found in a soiled gown with no care provided for several hours. The Assistant Director of Nursing (ADON) discovered the situation and noted that the assigned Certified Nursing Assistant (CNA) was unaware of their assignment to R3. The facility did not investigate why R3 had not received care for approximately seven hours, including whether R3 had been repositioned or received continence care. The NHA acknowledged the oversight but attributed it to other ongoing issues at the time. The third incident involved R5, who reported feeling mistreated by a CNA. The investigation lacked thoroughness, with only one staff statement and no resident interviews conducted to assess the impact on other residents. The Quality Management Director (QMD) completed the investigation but could not locate individual statements from involved staff. The NHA was new to the facility and did not complete the investigation, leading to a lack of comprehensive documentation and follow-up.
Failure to Ensure Proper Foot Care for a Resident
Penalty
Summary
The facility failed to ensure proper foot care for a resident, identified as R3, who was observed to have very long toenails in need of trimming. R3 has a medical history that includes hypertension, atrial fibrillation, and diabetes mellitus, and is assessed as having moderate cognitive impairment with a BIMS score of 12. The resident is dependent on assistance for putting on and taking off footwear. During an observation, the surveyor noted that R3's toenails on both feet were excessively long, and the CNA present indicated that R3, being diabetic, typically goes out for podiatry care. Upon reviewing R3's medical records, the surveyor was unable to find documentation of a recent podiatrist visit. The ADON and SSD were also unable to locate any podiatrist consults in R3's records. Despite the facility's understanding that R3's family arranges for podiatry care outside the facility, there was no evidence to confirm when R3 last saw a podiatrist. This lack of documentation and oversight in ensuring timely podiatry care for R3 led to the deficiency noted by the surveyor.
Latest citations in Wisconsin
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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