Avina Of Pewaukee
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukesha, Wisconsin.
- Location
- N26 W23977 Watertown Rd., Waukesha, Wisconsin 53188
- CMS Provider Number
- 525646
- Inspections on file
- 27
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Avina Of Pewaukee during CMS and state inspections, most recent first.
Surveyors found that residents were not consistently provided with a clean, comfortable, homelike environment due to inadequate linens and unrepaired wall damage. Multiple unit linen closets had little or no towels or sheets during morning care, and a cognitively intact resident reported that staff could not provide her scheduled shower because there were no towels. CNAs confirmed they had used all available towels for cares and sometimes had to wait or go to the laundry for supplies, while the laundry supervisor reported a broken washer, low overall linen supply, and no defined par levels for unit stocking. In addition, several occupied and unoccupied rooms had gouges, holes, and unpainted wall patches behind beds and near outlets, with the maintenance director acknowledging there was no regular schedule for inspecting or repainting rooms and that he relied on CNAs to report damage.
A facility failed to follow its abuse policy requiring immediate reporting to the Administrator when a CNA allegedly abused a resident with severely impaired decision-making and mild depression. A CNA reported witnessing another CNA manipulate and spit on the resident’s lunch and then allow the resident to eat it, after a verbal conflict in which the resident had insulted the CNA. The witnessing CNA informed an LPN after lunch, but the allegation was not promptly reported to the Administrator, and the accused CNA continued working through the remainder of the shift, part of the next shift, and returned the following day before being suspended. The Administrator later confirmed the allegation was reported only at the end of the shift and acknowledged that the abuse policy and procedures were not implemented as written.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with severely impaired decision-making and mild depression. A CNA allegedly handled and spat on the resident’s lunch food while using derogatory language, and the resident subsequently ate the food. Another CNA reported the incident to an LPN near the end of the shift, but the allegation was not immediately reported to the administrator, and the accused CNA remained in resident care areas for several more hours and returned to work the next day. The facility’s investigation was limited to verbal interviews with the two CNAs, lacked a statement from the LPN, and did not document the time of the incident or when it was reported, contrary to the facility’s abuse policy requiring immediate, thorough investigation and documentation.
A resident with multiple comorbidities, high Braden risk score, incontinence, and a history of resolved pressure injuries had physician orders and a care plan requiring an air mattress with function checks every shift, consistent with the facility’s pressure injury prevention policy. Over multiple observations on two days, the surveyor noted that the resident’s Proactive Protek Aire 8000 pump had no lights on and was not functioning while the resident lay in bed on his back with the head of the bed elevated. An LPN confirmed that air mattresses for residents who have them should be on but had not noticed the pump was off, and an RN/Unit Manager described expected checks of air mattress function; however, no additional explanation was provided by leadership for the ongoing lack of air mattress function.
A resident with multiple comorbidities, impaired gait, and a documented history of falls had a care plan and Kardex intervention requiring a reacher to be within reach while in bed to reduce fall risk. Surveyors repeatedly observed the resident in bed without the reacher accessible, instead finding it propped against a wall several feet away, and the resident reported not having the reacher the previous day. Staff confirmed the resident should have a reacher in bed and acknowledged moving it away, while nursing leadership affirmed that staff are expected to follow the care plan, demonstrating a failure to implement the ordered fall-prevention intervention.
Surveyors observed multiple used gloves and pieces of garbage outside the dumpsters, with dumpster lids left open. Staff interviews revealed uncertainty about responsibility for cleaning the area, though maintenance staff indicated they try to clean daily. Facility policy requires dumpster lids to be closed and the area to be kept clean, but these standards were not met.
Multiple residents reported and surveyors observed unclean and poorly maintained living areas, including dirty floors, stained walls, overflowing garbage, and inadequate housekeeping. Staff interviews confirmed that cleaning expectations were not consistently met, resulting in an environment that did not meet homelike standards.
Multiple residents receiving psychotropic medications for conditions such as anxiety, depression, and dementia with agitation did not have individualized behavior monitoring or nonpharmacological interventions documented in their care plans or CNA Kardexes. Staff interviews revealed a lack of training and inconsistent documentation practices, with behaviors often not recorded unless deemed unusual. Facility policies requiring person-centered care planning and nonpharmacological approaches prior to medication use were not followed, resulting in inadequate monitoring and documentation of psychotropic medication effectiveness and necessity.
The facility did not provide a consistent, individualized activity program for several residents, including those with severe cognitive and physical impairments. Observations showed residents left without meaningful engagement for extended periods, and care plans often lacked personalized, measurable goals or specific preferred activities. Activity staff and documentation revealed gaps in understanding and implementing resident preferences, resulting in unmet physical, mental, and psychosocial needs.
Several residents with complex medical needs did not have their weights consistently monitored or documented as required by care plans and physician orders. Staff interviews revealed confusion about the process for obtaining and recording weights, and there was a lack of documentation for refusals. Significant weight loss in some residents went unreported, and care plan interventions such as offering food substitutes and documenting meal preferences were not reliably implemented. These failures prevented accurate assessment and timely intervention for residents' nutritional status.
Several residents reported that hot foods were often served cold and unpalatable, with surveyor observations confirming that food temperatures did not meet facility policy standards. Staff acknowledged that food should be served at appropriate temperatures, but both resident feedback and test tray checks showed ongoing issues with food quality and temperature.
Multiple residents repeatedly reported concerns during Resident Council meetings about staff using ear buds and cell phones while providing care, including during medication administration and personal care. Residents described feeling frustrated and that their care was negatively affected. Despite these ongoing complaints, facility leadership acknowledged the issue but only addressed it on a case-by-case basis, without implementing a broader follow-up or process improvement plan as required by facility policy.
The facility did not ensure sufficient nursing staff to meet resident needs, resulting in prolonged call light wait times and periods with no staff present in resident areas. Multiple cognitively intact residents reported ongoing delays in receiving assistance, especially during shift changes, and staff confirmed that CNAs were often stretched between multiple areas, making timely responses difficult.
Surveyors found that drugs and biologicals were not consistently labeled or stored according to professional standards, with multiple instances of undated, expired, or improperly stored medications, loose and unlabeled pills in medication carts, and incomplete temperature logs for vaccine storage. Staff interviews confirmed uncertainty about medication handling and acknowledged these practices did not follow facility policy.
A resident with severe cognitive and physical impairments was repeatedly prevented from self-propelling their wheelchair due to staff engaging the rear wheel locks, which the resident could not remove independently. Staff confirmed that the use of wheel locks in this manner constituted a restraint, and the facility's policy only permitted their use during transfers, not for restricting movement at other times.
Two residents did not have current advance directives or documentation of advance care planning discussions in their records. Staff interviews revealed inconsistent processes for obtaining, documenting, and following up on advance directives, particularly for residents transitioning from short-term to long-term care. The deficiency resulted from a lack of proactive and consistent adherence to facility policy regarding resident rights and advance directive documentation.
Facility staff did not consistently assess, document, or notify providers regarding changes of condition for three residents, including after a fall resulting in a hip fracture and during antibiotic treatment for infections. This included delays in assessment, incomplete pain management documentation, and lack of ongoing shift-by-shift monitoring as required by professional standards.
A resident with limited mobility and multiple diagnoses did not receive appropriate restorative care after a walking program was discontinued without documented medical reason or rationale. Despite therapy recommendations and the resident's expressed desire to continue walking, staff were unaware of the reason for discontinuation, and required documentation and communication were lacking.
Two residents signed binding arbitration agreements without being properly informed of their right to refuse or the 30-day window to rescind the agreement. Staff, including the Admissions Coordinator and Nursing Home Administrator, incorrectly explained the terms, and the facility's policy did not address the rescission process, leading to a lack of resident understanding.
A facility failed to report an allegation of neglect involving a resident who required assistance for toileting and mobility. Despite the resident's care plan, a night shift aide instructed the resident to walk to the bathroom unassisted. The incident was logged as a customer service issue, but the required report to the State Survey Agency was not submitted. The Nursing Home Administrator claimed the resident was cared for, but this did not comply with reporting policies.
A resident reported neglect when a night shift aide allegedly told him to walk to the bathroom alone, despite needing assistance from two staff members. The facility's investigation was inadequate, as it only involved interviewing the accused CNA and lacked documentation of other interviews or checks for neglect signs. The facility's policy for thorough investigations was not followed.
A resident's care plan was not updated to include person-centered interventions, despite having medical orders for frequent checks, oral care, and palm guard use. The facility's policy for toileting was not individualized, and there was no specific oral care policy. The Unit Manager admitted the omission was an oversight, as orders were entered but not followed through in the care plan.
Two residents with limited range of motion did not receive appropriate care to prevent further decline. One resident, with hemiplegia, was observed without the prescribed palm protector, which was often left on the dresser. Staff were unaware of their responsibility to apply it, leading to incorrect documentation. Another resident, with severe cognitive impairment, was also observed without the required palm guard, despite records indicating it should be worn at all times. The facility lacked a policy on the application of these devices, contributing to the deficiency.
A resident with a G-tube was not provided appropriate care, as the facility failed to maintain the head of the bed elevated during feeding and did not administer the feeding at the prescribed rate. Additionally, feeding equipment was not labeled or dated, and there was no assessment or order for the G-tube securement device. Staff interviews revealed a lack of adherence to proper procedures, contributing to the deficiency.
A resident's medical record lacked complete and accurate information regarding psychiatric consults and talk therapy documentation. Despite having a care plan addressing psychiatric conditions, the initial psychiatric consult and talk therapy notes were missing from the EMR. The NHA acknowledged the absence and uncertainty about the records' location, while the LCSW did not document the therapy due to the lack of a full assessment, assuming the NHA would do so.
Inadequate Linens and Poor Room Maintenance Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, including adequate bed and bath linens, as required by its own policy. On multiple units, surveyors observed that nurse storage closets had little to no linens, particularly bath towels and sheets, during morning care times. One cognitively intact resident, with diagnoses including congestive heart failure, schizoaffective disorder bipolar type, morbid obesity, hypertension, and major depressive disorder, reported that staff washed her up but did not have any towels available on her scheduled shower day. Staff on the unit confirmed that they had used all available towels for resident care and were waiting for more linens before they could provide showers or additional care. Surveyors inspected the nurse storage closets on several units and found significant shortages. On one unit, the closet contained only a few pillowcases, washcloths, gowns, and bath blankets, but no bath towels or sheets. Another unit had only a small number of bath towels, washcloths, sheets, pillowcases, gowns, and one bath blanket, while a third unit’s closet had no linens or towels at all. CNAs reported that they typically relied on the closets being stocked but that on this day there were no linens on the floor, and they would have to go to the laundry if they needed supplies. One CNA stated she had started her shift earlier that morning and that the closet had not been stocked when she arrived, and another CNA stated she had to wait for towels to provide showers and would sometimes go back to the laundry to see if any were available. The Housekeeping/Laundry Supervisor reported that one of the facility’s washing machines had been broken for about a week to a week and a half and that this affected linen delivery. She stated linens were usually delivered once a day around noon, but with the broken machine, only a small amount could be delivered in the morning and again around noon. She also indicated that when she started one and a half to two months earlier, the facility was already low on linens, and that she had placed two linen orders but received only one. She did not have established par levels for each unit and instead estimated daily quantities for the small closets. At the time of the survey, the available clean towels and washcloths on a linen cart were fewer than the facility’s census, and additional towels and washcloths ordered previously still needed to be washed. The supervisor acknowledged she had not checked the unit closets that morning due to being short-staffed. In addition to linen shortages, surveyors observed multiple resident rooms with damaged walls, including gouges, holes, and unpainted patches, which affected the homelike environment. One resident’s room had a large patched area behind the headboard that had not been painted, and the resident stated that work had been started but not completed for some time. Other rooms, both occupied and unoccupied, had multiple gouges and holes of varying sizes in the wallboard behind beds and near outlets, as well as a missing corner guard extending several feet in one room. Some residents reported that the damage had been present for a while. The Maintenance Director stated he relied on CNAs to report such issues, that there was no set schedule for checking resident rooms for wall damage, and that he had not painted any rooms on one side of the building during his nearly two years at the facility, citing the need to move residents out of rooms to complete painting. The facility’s written policy, last reviewed in February 2025, requires that housekeeping and maintenance services be provided as necessary to maintain a sanitary, orderly, and comfortable environment, and that bed and bath linens be provided and maintained in clean and good condition. Despite this, the observations and staff interviews showed that residents experienced delays in showers and personal care due to lack of towels, and that multiple rooms had unrepaired or incompletely repaired wall damage. When informed of the concerns about inadequate linens and environmental conditions, the Nursing Home Administrator and Director of Nursing did not provide additional information to the surveyor at that time.
Failure to Immediately Report and Act on Allegation of CNA Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was immediately reported to the Nursing Home Administrator and/or Grievance Officer, as required by its Abuse, Neglect, and Exploitation policy. The policy states that all alleged violations must be reported to the Administrator and appropriate agencies immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. It also requires immediate response to protect the alleged victim and ensure residents are protected from physical and psychosocial harm during and after investigations. Despite these written procedures, the allegation involving a CNA and a resident was not promptly reported to the Administrator, and the CNA was not immediately removed from resident care areas. The resident involved had a Quarterly MDS showing a Brief Interview for Mental Status score of 9, indicating severely impaired skills for daily decision-making, and a Patient Health Questionnaire score of 6, indicating mild depression. The resident had no upper extremity range of motion impairment, but had lower extremity range of motion impairment bilaterally, and was independent with eating, dressing, and mobility, with supervision for showers and set-up for transfers. On the day of the incident, a CNA (CNA-D) reported that another CNA (CNA-E) reacted to a verbal exchange with the resident by referring to the resident in derogatory terms, manipulating the resident’s food with bare hands, and spitting on the food on the resident’s lunch tray, then stating an intention to watch the resident eat the contaminated food. CNA-D confirmed that the resident was not stopped from eating the food. After witnessing the incident, CNA-D reported it to an LPN (LPN-F) at the nurse’s station after lunch. While they were at the nurse’s station, CNA-E approached and stated, “Guess what? She ate it.” The facility’s Nursing Home Resident Mistreatment, Neglect, and Abuse Report later documented that the Administrator was notified on the date of the incident, but the Misconduct Incident Report and time records showed that CNA-E continued working until the end of the shift and into part of the next shift, and also returned to work the following day before being suspended. The Administrator confirmed that the allegation was reported at the end of the shift and acknowledged that the facility’s abuse policy and procedure were not implemented, as the allegation was not immediately reported and the CNA was not promptly removed from resident care areas. No additional explanation was provided by the facility for the delay in reporting, which allowed the CNA to remain on duty and continue to have contact with the resident and other residents.
Failure to Thoroughly Investigate Alleged Abuse and Delay in Reporting
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse involving one resident and a CNA, as required by its Abuse, Neglect, and Exploitation policy. The policy mandates immediate investigation of suspected abuse, identification and interviewing of all involved persons, complete and thorough documentation, and protection of residents from harm during and after investigations. The facility’s written procedures also require prompt reporting of all alleged violations to the administrator and state agencies within specified timeframes, and immediate actions to protect the alleged victim and other residents. The resident involved had a Brief Interview for Mental Status score of 9, indicating severely impaired decision-making skills, and a Patient Health Questionnaire score of 6, indicating mild depression. The resident had no upper extremity range of motion impairment, bilateral lower extremity range of motion impairment, and was independent with eating, dressing, and mobility, requiring supervision for showers and set-up for transfers. On the date of the incident, a CNA (CNA-D) reported that another CNA (CNA-E) referred to the resident using derogatory language, handled the resident’s food with bare hands, ran fingers through the food, and spat on the food on the lunch tray, stating an intention to watch the resident eat it. CNA-D stated that the resident ate the food and that CNA-E later commented, “Guess what? She ate it,” and indicated an intention to “mess with” the resident again the following day. The facility submitted a mistreatment, neglect, and abuse report the day after the incident, documenting that CNA-D observed CNA-E spit on the resident’s food and reported the incident to an LPN (LPN-F), and that the administrator was notified that same day. However, the surveyor determined that LPN-F learned of the allegation near the end of the first shift (which ends at 2:30 PM) and did not immediately report it to the administrator, allowing CNA-E to remain in the facility and continue working in resident care areas until 8:45 PM. The facility’s investigation consisted only of verbal interviews with CNA-D and CNA-E, did not include a statement from LPN-F beyond whether the incident was witnessed, and failed to document the time the incident occurred or the time the allegation was reported to the administrator. The administrator acknowledged the surveyor’s concern that the allegation of abuse was not thoroughly investigated, and no additional information was provided to explain the incomplete investigation.
Failure to Ensure Functioning Air Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a high‑risk resident received necessary pressure injury prevention services as required by physician orders, the care plan, and facility policy. The facility’s pressure injury policy states a commitment to preventing avoidable pressure injuries and providing appropriate treatment and services. The resident had a physician order dated 3/14/24 directing that the air mattress function be checked to ensure the green light is on and, if the light is red, to turn the air mattress on every shift. The resident’s care plan and Kardex also included an intervention to check the function of the air mattress every shift. The resident had multiple diagnoses including diabetes mellitus, dementia, congestive heart failure, major depressive disorder, atrial fibrillation, and hypertension, and was identified as high risk for pressure injuries with a Braden score of 10. The resident was dependent for toileting hygiene and rolling, always incontinent of bowel and bladder, and had a history of pressure injuries to the buttocks and right medial heel that had resolved on 2/25/26. The Pressure Ulcer/Injury CAA documented contributing factors such as ADL/functional/mobility impairment and incontinence, and indicated that licensed nurses were to assess skin weekly and implement proper interventions, with caregivers assisting with repositioning at least every two hours. Despite these identified risks and documented interventions, surveyor observations on two consecutive days showed that the resident’s Proactive Protek Aire 8000 air mattress pump was not functioning on multiple occasions, with no lights lit on the pump unit attached to the footboard of the bed. The resident was repeatedly observed lying in bed on his back with the head of the bed elevated while the air mattress pump remained off. When questioned, an LPN acknowledged that air mattresses for residents who have them should be on and stated they had not noticed the pump was off, explaining they usually complete the TAR at noon and suggesting a generator check may have shut off the air mattress. The RN/Unit Manager stated that nurses should check orders, listen for alarms, and that staff should feel the mattress during cares, but no explanation was provided by leadership for why the resident’s air mattress was not functioning during the observed periods.
Failure to Implement Care-Planned Reacher Intervention for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as at risk for falls. The resident had multiple diagnoses, including congestive heart failure, schizoaffective disorder bipolar type, morbid obesity, hypertension, major depressive disorder, dementia, COPD, weakness, and physical performance limitations affecting balance, gait, strength, and endurance. The resident’s fall CAA documented that falls were triggered secondary to impaired gait and mobility and the level of assistance required with transfers, with contributing factors including a history of falls prior to admission and multiple comorbidities. The resident’s care plan and Kardex specified an intervention that the resident was to have a reacher within reach while in bed, and the resident had sustained a fall from bed earlier in the month. On multiple observations by the surveyor while the resident was in bed, a reacher was not within the resident’s reach despite the care plan requirement. The reacher was observed propped against a wall behind a box near the television, approximately four feet from the bed, and the resident reported not having a reacher while in bed on the prior day. Staff confirmed that the resident should have a reacher while in bed and acknowledged moving the reacher away from the resident that morning. The RN/Unit Manager confirmed that staff are expected to follow the Kardex and care plans. The Nursing Home Administrator and DON were informed of the surveyor’s observations, and no explanation was provided as to why the resident did not have the reacher within reach while in bed as required by the plan of care.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as required by its own policy. During an initial kitchen tour, surveyors observed multiple used gloves and pieces of garbage outside the facility's dumpsters, and noted that the dumpster lids were left open. The Assistant Dietary Manager was unsure who was responsible for picking up the garbage, while the Maintenance Director later clarified that maintenance staff are responsible and attempt to clean the area daily. Both the Maintenance Director and the Nursing Home Administrator confirmed that dumpster lids should be closed when not in use and the surrounding area should be free of garbage. These observations and staff interviews demonstrate that the facility did not maintain the cleanliness of the dumpster area or ensure that refuse containers were kept covered, as required by policy.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents. Several residents voiced concerns about the cleanliness and condition of their rooms and common areas. Observations included dirty floors, peeling plaster, possible stains on walls, holes in walls, missing shower heads, non-functioning lights, and unclean bathroom fixtures. Residents reported that their rooms were not cleaned adequately, with some describing the environment as filthy and expressing frustration over persistent issues such as overflowing garbage bins, sticky floors, and visible dirt or marks on walls and floors. Specific examples included a resident who had recently moved to a new unit and found her room dirty, with peeling plaster, a suspicious pinkish/red substance on the wall, a hole behind the door, and a missing shower head. Another resident reported that her bedroom and bathroom were consistently dirty, with bugs present and garbage overflowing. Surveyors observed these conditions firsthand, noting dirty floors, splatters on walls, and sticky surfaces that caused shoes to stick to the floor. Residents also indicated that housekeeping staff did not clean thoroughly, and some attempted to clean their own rooms due to dissatisfaction with the facility's cleaning practices. Interviews with staff confirmed that cleaning procedures were expected to be performed daily, including deep cleaning of bedrooms and common areas, but these expectations were not met in practice. Maintenance staff acknowledged that some areas had not been remodeled or repaired, and housekeeping supervisors were made aware of the ongoing concerns. Despite the facility's cleaning checklist and stated protocols, the observed conditions and resident feedback demonstrated a failure to maintain a homelike and comfortable environment as required.
Failure to Monitor and Document Psychotropic Medication Use and Nonpharmacological Interventions
Penalty
Summary
Surveyors identified deficiencies related to the use and monitoring of psychotropic medications for multiple residents with diagnoses such as anxiety, depression, dementia with agitation, and insomnia. Physician orders for these residents included various psychotropic medications, such as lorazepam, quetiapine, bupropion, buspirone, venlafaxine, fluoxetine, aripiprazole, and trazodone. Despite these orders, the facility failed to ensure that resident-specific targeted behaviors were identified, monitored, and documented to assess the effectiveness and necessity of these medications. Care plans and CNA Kardexes often lacked documentation of the specific behaviors that triggered medication use, as well as nonpharmacological interventions to address these behaviors. Interviews with staff, including CNAs, medication technicians, LPNs, and a social worker, revealed a lack of awareness and training regarding behavior monitoring and the use of nonpharmacological interventions. Staff described resident behaviors such as agitation, restlessness, yelling, and frustration, but these were not consistently documented in care plans or the electronic health record. In several cases, staff relied on as-needed medication administration without clear documentation of the behaviors leading to medication use or the effectiveness of the interventions. Additionally, staff reported that they would only document behaviors in progress notes if they were unusual, despite some residents exhibiting daily symptoms. Facility policies required the development and implementation of baseline care plans that include person-centered interventions and the use of nonpharmacological approaches before psychotropic medications are used. However, the survey found that these policies were not followed, as evidenced by the lack of individualized behavior monitoring, absence of nonpharmacological interventions in care plans, and insufficient documentation of the rationale for psychotropic medication use. This resulted in the facility not meeting professional standards of quality care for residents receiving psychotropic medications.
Failure to Provide Individualized and Ongoing Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident, as evidenced by observations, interviews, and record reviews for four residents. One resident with severe cognitive impairment and multiple diagnoses, including dementia and depression, was observed sitting for extended periods without any activities, conversation, or stimulation, despite documentation indicating limited participation in group activities such as bingo and movies. Staff discussions revealed uncertainty about the resident's preferences and inconsistent efforts to engage the resident in meaningful activities. Another resident, who was cognitively intact and had chronic medical conditions, expressed dissatisfaction with the variety of activities available, stating there was nothing to do. The resident's care plan listed only a few leisure pursuits and lacked measurable goals or evidence of personalization. Activity participation records showed sporadic involvement in activities, and the Activity Director acknowledged that care plans may not clearly communicate residents' preferences or goals to new staff. Two additional residents with severe cognitive impairment and significant physical limitations had care plans that either lacked an activities component or did not specify preferred activities. Documentation showed minimal participation in activities, with little detail on the nature or enjoyment of the activities. Interviews with the Activity Director indicated a lack of awareness of some residents' preferences and an absence of individualized activity planning in the care plans. These deficiencies demonstrate the facility's failure to implement its own policy requiring activities to be tailored to each resident's interests, abilities, and preferences.
Failure to Consistently Monitor and Document Resident Weights and Nutrition Interventions
Penalty
Summary
The facility failed to consistently monitor and document residents' weights as required by their care plans, physician orders, and facility policy. Multiple residents, including those with significant medical histories such as cerebral palsy, diabetes, chronic heart failure, chronic kidney disease, malnutrition, and dysphagia, did not have monthly or weekly weights recorded as ordered. In several cases, there was no documentation of refusals, and staff interviews revealed confusion and inconsistency regarding the process for obtaining, recording, and following up on missing weights. For example, one resident was missing several months of weight documentation, and staff could not confirm or provide evidence of refusals, despite the resident stating they did not refuse to be weighed. Another resident experienced a significant weight loss of over 13% in just over two months, but weekly weights were not initiated until after family intervention. The care plan required offering food substitutes if less than 50% of a meal was consumed, but the resident reported not being offered alternatives and that their meal preferences were not documented on meal tickets. Staff interviews confirmed that likes and dislikes were not consistently recorded or communicated, and that interventions outlined in care plans were not always implemented. Additional deficiencies included a resident not being weighed upon admission despite hospital discharge instructions for daily weights due to heart failure, and another resident with a history of malnutrition and dysphagia not being weighed monthly, resulting in an unreported significant weight loss. The Registered Dietician and Nurse Practitioner both indicated that missing weights prevented them from accurately assessing nutritional status and implementing timely interventions. Facility policy required regular weight monitoring and prompt notification of significant changes, but these procedures were not reliably followed, leading to gaps in care and monitoring for multiple residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures for several residents. Multiple residents with intact cognitive status reported that hot foods were frequently served cold, and cold foods were not consistently kept at appropriate temperatures. Specific complaints included food items such as french fries, potato dishes, and noodles being served cool or undercooked, and entire meals being unappetizing or left uneaten due to temperature issues. One resident noted that their hallway was typically the last to be served, resulting in consistently cold food. Surveyor observations confirmed these concerns, with test tray temperatures for hot foods measured well below the required 135°F and cold foods only slightly above the 41°F threshold. The facility's own policy required hot foods to be served at a minimum of 135°F and cold foods at 41°F or below, but these standards were not met during the survey. Staff interviews, including those with the Assistant Dietary Manager and the Nursing Home Administrator, acknowledged the expectation that foods should be served at appropriate temperatures and be palatable. Despite this, both resident interviews and direct surveyor observations demonstrated a pattern of noncompliance, with food quality and temperature concerns affecting at least four residents and confirmed by a test tray evaluation.
Failure to Address Resident Council Grievances on Staff Cell Phone and Ear Bud Use
Penalty
Summary
The facility failed to ensure that grievances and recommendations raised during Resident Council meetings were acted upon promptly, as required by facility policy. Over a three-month period, Resident Council meeting minutes consistently documented concerns from multiple residents regarding staff using ear buds and cell phones while providing care, including during medication administration and personal care tasks. Residents reported that this behavior occurred frequently, with some stating it happened daily or several times a week, and expressed feelings of frustration, irritation, and a perception that their care was negatively impacted. During interviews, residents confirmed that the issue persisted and that the facility's response was limited to verbal assurances that staff would be spoken to about the matter. Despite the recurring nature of the complaints, facility leadership, including the DON and NHA, acknowledged awareness of the concerns but indicated that their approach was to address incidents as they were observed rather than implementing a broader or systematic follow-up in response to the Resident Council's documented grievances. Documentation provided to surveyors showed that staff education on cell phone and ear bud use had occurred, but there was no evidence of a process improvement plan or additional corrective action following the continued reports from residents. The facility's policy required action on Resident Council concerns and communication of decisions back to the Council, which was not demonstrated in this case.
Failure to Provide Adequate Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by prolonged call light response times and lack of staff presence in resident areas. Observations included a 45-minute period with no staff present on the 200 hall and a 45-minute call light wait time. Residents reported ongoing issues with long call light wait times, particularly during shift changes, and expressed frustration and anger over delays in receiving assistance. Resident council minutes also documented repeated concerns about untimely responses to call lights. Specific examples included a resident with a BIMS score of 15, indicating cognitive intactness, who observed staff frequently neglecting call lights in favor of personal activities such as using phones and taking cigarette breaks. Another resident, also cognitively intact and requiring assistance with personal care, reported waiting 30 minutes for help while experiencing discomfort, with no staff present in the hallway. Staff interviews confirmed that CNAs were often responsible for multiple pods, making it difficult to respond promptly to call lights, and that long wait times were a common issue.
Deficient Medication Storage, Labeling, and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's storage and labeling of drugs and biologicals. Several residents' medications, including eye drops and oral solutions, were found without required open dates, expiration dates, or proper storage conditions. For example, one resident's artificial tears and another's Azopt eye drops lacked open dates, and Latanoprost eye drops were not refrigerated as required. Another resident's Anbesol had an unreadable expiration date, and artificial tears for a different resident were past the discard date. Staff interviews confirmed uncertainty about when medications were opened or should be discarded, and acknowledged that medications should be labeled and stored according to policy. Medication carts were observed to contain loose, unlabeled, and expired medications. One cart had a loose pill and an unlabeled bottle of artificial tears, while another had multiple loose pills and expired vitamin B12. An insulin pen was found without a cap or label to identify the resident, and staff could not determine its owner. Staff interviews revealed a lack of knowledge regarding the identification and proper storage of these medications, and staff acknowledged that such practices were not in line with facility policy. In the medication storage room, open bottles of TB testing solution were found without open dates, and the vaccine refrigerator temperature logs were incomplete, with several days missing recorded temperatures. The Director of Nursing confirmed that medications should be dated when opened, labeled, and stored appropriately, and that temperature logs should be completed as per policy. These findings demonstrate a failure to follow established procedures for medication storage, labeling, and documentation.
Resident Restrained by Wheelchair Locks Without Medical Necessity
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations was placed in a low Broda chair with the rear wheel locks engaged, preventing the resident from self-propelling the chair. The resident, who has diagnoses including progressive supranuclear ophthalmoplegia, dementia, and chronic respiratory failure, was observed on multiple occasions attempting to move away from the table and self-propel, but was unable to do so due to the engaged wheel locks. The resident was unable to reach or disengage the wheel locks independently. Staff members, including a Certified Nursing Assistant (CNA) and the Activities Director (AD), were observed engaging the wheel locks while the resident was at the dining table or after being assisted around the facility. The locks were only disengaged by staff when the resident needed to move, at which point the resident immediately began to self-propel. Interviews with staff confirmed that the wheel locks could act as a restraint and that the resident could not remove them independently. The facility's policy defines a physical restraint as any device that the resident cannot remove easily and that restricts freedom of movement. Staff interviews further confirmed that wheel locks should only be used during transfers and that engaging them at other times, especially when the resident cannot remove them, constitutes a restraint. The care plan indicated the resident was able to self-propel, but the use of wheel locks in this manner restricted the resident's movement without a documented medical need.
Failure to Ensure Advance Directive Documentation and Resident Rights
Penalty
Summary
The facility failed to ensure the right of residents to request, refuse, or discontinue treatment and to formulate an advance directive for two residents. For both individuals, their medical records did not contain current copies of their advance directives, nor was there documentation of discussions regarding advance care planning, aside from code status. The facility's policy requires that, upon admission, staff determine if a resident has an advance directive, provide information about advance directives, and document any discussions or refusals. However, these steps were not consistently followed for the residents in question. For one resident, there was no evidence in the record of an advance directive or documentation of a discussion about advance care planning options. Interviews with the Social Services Director (SSD) and Social Worker (SW) revealed that while the resident had been asked about Power of Attorney documents, he wanted to consult with family before making decisions, and there was no established process to ensure follow-up or documentation, especially for residents transitioning from short-term to long-term care. The SW only addressed the issue after being prompted by the SSD due to the surveyor's inquiry, indicating the process was reactive rather than proactive. For the second resident, the record also lacked evidence of an advance directive or documentation of a discussion. The SSD was aware that the resident had an advance directive, but the document had not been obtained, despite the resident's lengthy stay. The Nursing Home Administrator confirmed that the Social Worker is responsible for obtaining and documenting advance directives, but acknowledged that follow-up was inconsistent and sometimes reliant on access to hospital records or waiting for family members to provide documents. The lack of timely documentation and follow-up led to the deficiency.
Failure to Assess and Document Changes of Condition and Treatment
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards of practice for three residents, resulting in deficiencies related to assessment and documentation during changes of condition. In one case, a resident with multiple diagnoses, including seizure disorder, diabetes, and cognitive impairment, experienced a fall and subsequently developed increased pain and decreased range of motion. Despite these changes, there was a delay in further assessment and provider notification, and pain assessments and interventions were inconsistently documented. The resident's care plan did not specify a pain goal or PRN pain medication administration, and non-pharmacological interventions were not consistently attempted or documented. Two other residents, both of whom experienced changes of condition related to infection and were started on antibiotic therapy, did not have documented assessments throughout the course of their treatment. For these residents, there was a lack of ongoing shift-by-shift documentation of vital signs and clinical status during the antibiotic course, as required by facility expectations and professional standards. Interviews with facility staff, including the DON, Nurse Manager, and Infection Preventionist, confirmed that ongoing assessment and documentation were expected but not performed. The facility did not have a formal Change of Condition policy but stated adherence to AMDA guidelines, which require further assessment and provider notification for acute changes such as new or worsening pain, especially following trauma. The lack of timely assessment, documentation, and provider notification for residents experiencing changes of condition, including after falls and during infection treatment, directly led to the identified deficiencies.
Failure to Maintain Resident Mobility Program
Penalty
Summary
A deficiency occurred when a resident with limited mobility, who had diagnoses including polyneuropathy, unilateral primary osteoarthritis of the left knee, and major depressive disorder, did not receive appropriate services to maintain or improve mobility. The resident had previously been on a walking program as recommended by therapy, which involved ambulation with assistance and the use of a walker and wheelchair follow for up to 20 feet, twice daily. Documentation showed the resident participated in the program on several occasions before it was discontinued. There was no documented medical reason or rationale for discontinuing the walking program, and the resident expressed frustration about not being able to continue walking, stating a desire to walk and concern about losing mobility. Interviews with facility staff, including a CNA, LPN, PTA, unit manager, and DON, revealed a lack of awareness or documentation regarding the reason for discontinuing the walking program. The facility's policy required communication and documentation of therapy recommendations and restorative programs, but there was no evidence that the discontinuation was communicated or justified. The absence of documentation and follow-through resulted in the resident not receiving the restorative care necessary to maintain or improve mobility, contrary to facility policy and the resident's expressed wishes.
Failure to Properly Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents and their representatives were properly informed about the binding arbitration agreement, specifically regarding their right to refuse to sign and the 30-day window to rescind the agreement after signing. In two reviewed cases, one resident was unable to articulate any understanding of the arbitration agreement or recall being informed about it, despite having signed the document. The other resident misunderstood the terms, believing she could rescind the agreement at any time, which was also incorrectly communicated by the Admissions Coordinator and the Nursing Home Administrator. Both staff members were unaware of the specific 30-day rescission period, and the facility's policy did not address the process for signing or the rescission window. The arbitration agreement itself did include language about the 30-day rescission period, but this information was not effectively communicated to the residents. Interviews with the residents and staff revealed a lack of understanding and incorrect explanations regarding the agreement and the time frame for rescinding it. The admissions process included the arbitration agreement as part of a lengthy contract, and staff routinely presented the agreement as something that could be changed at any time, contrary to the actual terms. This resulted in residents signing agreements without full comprehension of their rights or the specific time limits involved.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident, identified as R5, to the State Survey Agency within the required 24-hour timeframe. The facility's policy mandates immediate reporting of such allegations, but this was not adhered to in this case. R5, who was admitted with multiple diagnoses including rhabdomyolysis and acute respiratory failure, required assistance from two staff members for toileting and moving between surfaces. Despite this, a night shift aide reportedly told R5 to walk to the bathroom without assistance, which was contrary to the resident's care plan. The incident was documented in the facility's grievance log as a customer service/interaction issue, but the necessary Department of Health Services Form, F-62617, was not submitted to notify the State Survey Agency of the potential neglect. When questioned by the surveyor, the Nursing Home Administrator stated that the resident had been cared for and toileted throughout the night, which was why the report was not made. However, this explanation did not align with the facility's policy requirements for reporting such allegations.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect made by a resident, identified as R5, who was cognitively intact and required assistance from two staff members for toileting and movement. On April 29, 2024, R5 reported that a night shift aide told him he could walk to the bathroom alone, which contradicted his assessed needs. The facility's investigation was limited to interviewing the accused CNA, who denied the allegation, and did not include interviews with other staff or residents who might have had relevant information. Additionally, there was no documentation of interviews with other staff or residents, and the facility did not check the bed linen for signs of neglect. The Director of Nursing and the Nursing Home Administrator acknowledged the lack of thorough investigation when questioned by the surveyor. The facility's policy required a comprehensive investigation involving interviews with all relevant parties and documentation of findings, which was not followed in this case. The facility also faced issues accessing the accused CNA's performance evaluation due to technical difficulties with their HR system, further complicating the investigation process.
Failure to Update Resident Care Plan with Person-Centered Interventions
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R4, to include person-centered interventions. R4 had several medical orders documented in the Medication and Treatment Administration Record (MAR and TAR) that were not incorporated into the care plan or the Kardex. These orders included checking and changing the resident every two hours, providing oral care twice daily, and monitoring the use of a palm guard. Despite these orders, the care plan did not reflect the resident's incontinence needs or oral care requirements, and the Kardex lacked interventions related to these needs. The deficiency was identified during a survey when the surveyor reviewed R4's care plan and Kardex and found omissions in documenting the resident's needs for toileting assistance and oral care. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the facility's policy for toileting was not individualized for R4, and there was no specific oral care policy. The Unit Manager admitted that the omission was an oversight, as the orders were entered but not followed through in the care plan. The DON acknowledged that it was expected for these needs to be documented in the care plan.
Failure to Apply Palm Protectors for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that two residents with limited range of motion received appropriate treatment and services to prevent further decline. Resident R3, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was observed multiple times without the prescribed palm protector on the right upper extremity. Despite physician orders and care plans indicating the necessity of the palm protector to prevent further contracture, staff failed to apply it consistently. Observations revealed that the palm protector was often left on the dresser, and staff were unaware of their responsibility to apply it, as evidenced by the CNA's lack of knowledge and the LPN Supervisor's incorrect documentation in the treatment administration record. Similarly, Resident R4, who has severe cognitive impairment and range of motion limitations, was observed without the required palm guard on the left hand. The care plan and treatment administration record indicated that the palm guard should be worn at all times, yet observations showed that it was not applied, and staff had signed off on its application without actually placing it on the resident. When questioned, the resident confirmed that staff had not been applying the palm guard recently, and it could not be located in the room. The facility lacked a policy regarding the application of splints and palm guards, contributing to the oversight in care. Both residents were not provided with the necessary interventions to maintain or improve their range of motion, as required by their care plans and physician orders. The absence of a clear policy and staff education on the application of these devices led to the deficiency in care for these residents.
Deficiency in Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding through a gastrostomy tube (G-tube) was provided with appropriate treatment and services to prevent complications. The resident, who has a history of hemiplegia, dysphagia, and vascular dementia, was observed on multiple occasions with the head of the bed lowered flat while tube feeding continued, contrary to the facility's policy requiring the head of the bed to be elevated at least 30 degrees during feeding. Additionally, the resident's tube feeding was not administered according to physician orders, as the feeding rate was consistently observed at 50 ml/hour instead of the prescribed 75 ml/hour. The facility also failed to label and date the resident's feeding equipment, including the Osmolite 1.5 container, water bag, and syringe, which were observed without proper identification on several occasions. This lack of labeling and dating is a deviation from the facility's policy and standard practice, which requires containers to be labeled with the resident's name, flow rate, date, and time. Furthermore, there was no documented assessment or physician order for the resident's G-tube securement device, which was used to prevent the resident from tampering with the tube. Interviews with facility staff revealed a lack of awareness and adherence to proper procedures for managing tube feeding during personal care. A CNA was observed lowering the resident's head of the bed without stopping the tube feeding, and staff were not adequately informed about the correct feeding rate or the importance of checking physician orders before administering tube feeding. The facility's failure to follow established protocols and physician orders resulted in a deficiency in the care provided to the resident, potentially compromising their health and safety.
Incomplete Medical Records for Resident's Psychiatric Consults
Penalty
Summary
The facility failed to ensure that a resident's medical record contained complete and accurate information, specifically regarding psychiatric consults and talk therapy documentation. The resident, who had multiple diagnoses including Metabolic Encephalopathy, Malignant Neoplasm of Glottis, and Cognitive Communication Deficit, was admitted to the facility and later enrolled in hospice care. Despite having a comprehensive care plan that included revisions for psychiatric conditions such as psychosis, hallucinations, and anxiety, the initial psychiatric consult and talk therapy documentation were not accessible in the resident's electronic medical record (EMR) when requested by the surveyor. The Nursing Home Administrator (NHA) acknowledged the absence of the psychiatric information in the EMR and expressed uncertainty about its whereabouts. The Licensed Clinical Social Worker (LCSW) confirmed providing talk therapy to the resident but did not document it due to the lack of a full assessment, assuming the NHA would record the information. The surveyor's interviews with the NHA and Director of Nursing (DON) revealed that the facility was unable to locate the missing notes, resulting in the deficiency of not safeguarding resident-identifiable information and maintaining complete medical records as per professional standards.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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