Avina Of Weyauwega
Inspection history, citations, penalties and survey trends for this long-term care facility in Weyauwega, Wisconsin.
- Location
- 717 E Alfred St, Weyauwega, Wisconsin 54983
- CMS Provider Number
- 525315
- Inspections on file
- 38
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Avina Of Weyauwega during CMS and state inspections, most recent first.
A resident with COPD, heart disease, bipolar disorder, and pain disorder, who was cognitively intact and receiving multiple sedating medications (including scheduled lorazepam, gabapentin, acetaminophen, and PRN morphine), became lethargic, diaphoretic, and minimally responsive, leading to transfer to the ER. The MAR sent with the resident showed that HS medications had been administered, but the ADON later found those medications still in the med cart. An RN acknowledged documenting the HS medications as given on the MAR before attempting administration and then encountering the resident sweaty and refusing the medications. Leadership confirmed that documenting medications as administered prior to actually giving them was contrary to facility policy.
A resident with an indwelling urinary catheter received catheter care from staff without an active physician order in place. The care plan noted the catheter, but no current orders for the catheter or its care were found, and staff did not document catheter care due to the missing order. Staff interviews confirmed that care was provided without verifying or obtaining the necessary physician order.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
The facility did not complete the care plan within 7 days of the comprehensive assessment and did not ensure that a team of health professionals prepared, reviewed, and revised the care plan as required.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services to address their condition, resulting in a deficiency related to inadequate mental health and psychosocial care.
Staff did not follow infection control protocols during care for three residents, including failing to remove PPE when exiting a precaution room, not donning required gowns during transfers, not sanitizing shared equipment, and neglecting hand hygiene and glove changes during pericare. Clean items were contaminated by soiled gloves, and a used bed pan was improperly stored on the floor.
Two residents were exposed to accident hazards due to the facility's failure to enforce its smoking policy and elopement prevention measures. One resident repeatedly smoked in their room, with no updates to their care plan despite multiple violations and a history of fire-related incidents. Another resident, with cognitive impairment and a history of wandering, was found without a required WanderGuard device and was able to exit the building unsupervised, with staff failing to document or report these incidents. These actions and inactions resulted in immediate jeopardy findings.
Three residents receiving IV antibiotics experienced significant medication errors, including missed doses, unauthorized changes to physician orders, and lack of physician notification when doses were not administered. In each case, staff failed to clarify medication orders, did not follow proper procedures for order changes, and did not document or communicate missed doses to the appropriate medical providers.
The facility failed to maintain sanitary food preparation and dishwashing practices, including improper hand hygiene by kitchen staff during a Norovirus outbreak, lack of testing and logging for sanitizer bucket effectiveness, and inaccurate monitoring of dishwashing machine temperatures. Staff were observed handling dirty and clean dishes without proper handwashing or changing aprons, and logs for critical sanitation checks were either missing or falsified.
A facility failed to maintain an effective infection prevention and control program during a GI illness outbreak, with incomplete outbreak documentation, premature removal of residents from contact precautions, and inconsistent use of PPE and hand hygiene. Staff did not follow protocols for handling soiled linens, sanitizing shared equipment, or updating public health authorities, and there were discrepancies in illness tracking among staff. These lapses affected residents with various medical conditions and had the potential to impact all individuals in the facility.
Multiple residents reported excessive delays in call light response and assistance with basic needs, including toileting and feeding, due to insufficient nursing staff. Observations confirmed that only one CNA was present in the dining room to assist several residents, leading to delays in feeding and unmet requests for water. Staffing schedules showed that staff-to-resident ratios frequently fell below the facility's own guidelines, with as few as two staff members covering over 50 residents during some night shifts.
Surveyors found that medication carts were left unlocked and unattended, with resident information visible, and that narcotic medications were stored unsecured at the nurses' station. Additional issues included improperly labeled, undated, and expired medications in a medication cart, as well as expired medical supplies and an unlabeled pill container in a medication storage room. Staff interviews confirmed these practices did not follow facility policy for medication security and labeling.
Two residents did not receive timely or properly documented wound care, with one not having wounds assessed or treated upon admission and another having a dressing applied without a physician order or documentation. Staff interviews and record reviews confirmed lapses in following wound care protocols and documentation requirements.
A resident admitted with sepsis, diabetes, and a pre-existing pressure injury did not receive timely or accurate skin assessments or wound care. The facility failed to document all wounds, delayed obtaining wound care orders, and did not provide necessary treatments, resulting in incomplete care and lack of evidence regarding the number and status of pressure injuries.
A resident with an activated POAHC following hospitalization for sepsis was allowed to sign multiple consent forms upon readmission, despite a Statement of Incapacity in the medical record. Facility staff failed to recognize and act on the POAHC status, and the resident's representative was not notified of the activation until later. Staff interviews revealed a lack of awareness and inconsistent review of advance directive paperwork, resulting in the resident's representative not being able to exercise the resident's rights.
The facility did not ensure PASRR requirements were met for two residents with mental illness who were admitted under a 30-day hospital discharge exemption. Both residents' records lacked the required County exemption form and timely PASRR Level II Screens, with documentation only submitted after surveyor inquiry.
A resident with CHF did not receive a required physician visit according to the facility's alternating schedule, as only nurse practitioner visits were documented during the relevant period. Attempts by the physician to see the resident were not documented in the medical record, and the absence of a completed physician visit note led to a deficiency.
Three residents were found with medications at their bedside without proper physician orders or documented self-administration assessments, and one resident did not receive prescribed bedtime medications with no timely physician notification. Facility policy requires orders and assessments for self-administration and bedside storage, which were not completed for all medications involved.
Two residents who had provided consent for influenza and pneumococcal vaccines did not receive the immunizations as indicated in their records. One resident with Parkinson's disease and a POAHC consented to the flu vaccine, while another with CHF consented to the pneumococcal vaccine; both vaccines were not administered despite proper documentation and eligibility.
A resident with COPD and moderate cognitive impairment, whose POAHC provided signed consent for a COVID-19 vaccine, was not administered the vaccine by facility staff. The medical record lacked documentation of vaccine administration, and the Infection Preventionist confirmed the vaccine was not given.
The facility did not ensure that all staff, including several CNAs, received mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program as required by facility policy. Review of staff education records and administrator confirmation showed that QAPI education was not included in the training provided.
A resident requested a copy of their medical record, which was not provided within the facility's policy timeframe of 7 days. Instead, the record was mailed 25 days later. The Medical Records Coordinator cited workload and administrative review as reasons for the delay, while the Nursing Home Administrator believed requests should be fulfilled within 10 days, indicating a lack of adherence to policy.
The facility failed to maintain proper infection control practices for two residents. A resident with a suprapubic catheter did not receive care with the required gown use by a CNA, despite being on enhanced barrier precautions. Another resident, with multiple diagnoses and on EBP, did not receive proper hand hygiene and glove changes during care. Both deficiencies were confirmed by the DON and IP.
A resident with Parkinson's disease and psychosis did not receive proper monitoring and administration of clozapine due to an incorrect lab order and missed doses. This led to the resident experiencing psychosis symptoms and requiring emergency room treatment. Staff interviews revealed a lack of awareness and education regarding the specific lab requirements for clozapine monitoring.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. Multiple residents reported long wait times for call light responses, leading to incontinence and missed medications. Staff interviews confirmed the challenges of inadequate staffing, with agency staff often not showing up or leaving mid-shift. Despite management's claims of sufficient staffing, the lack of timely care persisted, affecting residents' quality of life.
A resident with Parkinson's disease and psychosis did not receive clozapine for four days, and the neurologist was not notified, contrary to facility policy. The resident, who had moderately impaired cognition, was hospitalized for increased behavioral symptoms, including attempting to ingest lotion. A neurology RN confirmed the neurologist was unaware of the missed doses, which are critical due to the medication's monitoring requirements.
The facility failed to provide appropriate care for three residents, including improper management of a DBS for a resident with Parkinson's, lack of updated assessments for a resident with cognitive decline, and inadequate oral care for a resident with fungal candidiasis. Staff were unaware of device functions, did not reassess consent capacity, and deviated from care plans, leading to deficiencies in resident care.
A resident fell due to improper transfer methods not aligned with their care plan, highlighting deficiencies in staff training and adherence to safety protocols. Additionally, the facility charged motorized wheelchair batteries in a poorly ventilated room, posing a fire hazard.
The facility failed to ensure accurate medication administration for two residents. One resident received multiple medications late over several days, while another did not receive scheduled pain medication on a night shift, leading to increased pain. Additionally, medications were left unsupervised with a resident who lacked a self-administration assessment. The facility's policies were not adhered to, resulting in these deficiencies.
A facility failed to report an alleged verbal abuse incident involving a CNA and a cognitively impaired resident to local law enforcement, as required by their policy. The incident was reported internally, and the accused CNA was suspended and later returned to work after completing relevant education. However, the Nursing Home Administrator did not notify law enforcement, resulting in a deficiency noted by surveyors.
A resident with a history of chronic respiratory failure and anxiety reported difficulty breathing and feeling like they were having a stroke. Despite these symptoms, nursing staff failed to adequately assess the resident or notify a physician. The resident's condition was not communicated to the night shift, and they were found unresponsive the following day, leading to a finding of immediate jeopardy due to the facility's failure to provide appropriate care.
The facility failed to ensure competent staff performed nail care and vital signs for residents. A resident on anticoagulant medication had their nails trimmed by a non-certified Hospitality Aide (HA), and multiple residents had their vital signs taken by HAs not enrolled in a CNA course. The Director of Nursing confirmed that HAs were not supposed to perform these tasks, and inconsistencies in task delegation were noted among staff.
Inaccurate MAR Documentation for Bedtime Medications
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure accurate documentation of medication administration for one resident. The facility’s medication administration policy required licensed nurses to administer medications as ordered, sign the MAR after administration, and document refusals. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including COPD, heart disease, bipolar disorder, and pain disorder, was ordered multiple sedating and pain medications, including scheduled lorazepam at bedtime, acetaminophen and gabapentin three times daily, and PRN morphine. On the night in question, the resident became lethargic, diaphoretic, minimally responsive to sternal rub, non-verbal, and unable to keep their eyes open, prompting staff to call 911 and send the resident to the ER. Documentation sent with the resident to the ER, specifically the MAR, indicated that the resident’s bedtime medications had been administered, but subsequent review and interviews revealed they had not been given. The ADON reported receiving conflicting accounts about whether the HS medications were administered and later located the HS medications still in the medication cart, while confirming that the MAR sent to the ER showed them as given. The RN on duty admitted that she documented the HS medications as administered on the MAR before attempting to give them and that, when she went to administer them, the resident was sweaty and refused the medications. The DON and ADON both confirmed that staff should not document medications as administered prior to actually administering them and that nursing staff were expected to follow the facility’s medication administration policy.
Lack of Physician Order for Indwelling Catheter and Catheter Care
Penalty
Summary
A resident with a diagnosis of benign prostatic hyperplasia was admitted and later readmitted to the facility with an indwelling urinary catheter. The resident's care plan documented the presence of the catheter and included interventions to monitor for discomfort, leaking, and obstruction. However, a review of the physician orders revealed there were no current orders for the urinary catheter or for catheter care. Staff provided catheter care without verifying the existence of an active physician order, and no documentation of catheter care was made on the Treatment Administration Record due to the absence of such an order. During interviews, staff acknowledged that they did not check for a current order before providing care and that clarification should have been sought upon the resident's readmission.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. Additionally, the care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the surveyor's review of facility practices and documentation.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified based on the lack of evidence that the resident received necessary care and interventions tailored to their mental health and psychosocial needs, as required by regulatory standards.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols for three residents during care activities. For one resident on enhanced barrier precautions (EBP), staff exited the resident's room without removing personal protective equipment (PPE), re-entered the room without donning new PPE, and transferred the resident using a lift without wearing required gowns. Additionally, the lift was not sanitized after use and was left in the hallway. Staff interviews confirmed knowledge of the correct procedures, but these were not followed during the observed events. During pericare for two other residents, staff did not change gloves or perform hand hygiene between dirty and clean tasks, and touched clean items in the residents' rooms with soiled gloves. In one instance, a used bed pan was stored on the floor of a resident's room. In another, clean washcloths were placed in an unsanitized sink and then used for pericare. Staff interviews confirmed that these actions were inconsistent with facility policy and proper infection control practices.
Failure to Prevent Accident Hazards: Unsafe Smoking and Elopement
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, resulting in deficiencies related to unsafe smoking practices and inadequate elopement prevention. One resident, who was cognitively intact and had a history of noncompliance with smoking policies, repeatedly smoked cigarettes in their room despite the facility's policy requiring smoking only in designated areas. The resident's care plan was not updated in response to multiple documented violations, and staff failed to revise the smoking assessment or implement additional safety interventions after incidents, including one where a hot cigarette butt singed trash in a shared bathroom. The resident's medical record also indicated a history of disruptive behavior and previous fire-related incidents in another facility, yet the facility did not adjust the care plan or restrict access to smoking materials accordingly. Another resident, with moderate cognitive impairment and a history of exit-seeking behavior, was not adequately supervised to prevent elopement. The resident's care plan required the use of a WanderGuard device and securing the window to prevent unsupervised exits. However, staff failed to ensure the WanderGuard was consistently in place and functioning, and the window in the resident's room was found to open fully, contrary to care plan instructions. The resident was observed without a WanderGuard on multiple occasions and was able to exit the building unsupervised through an emergency exit. Staff interviews revealed that the resident frequently removed the WanderGuard, and incidents of elopement were not documented or reported to administration as required. The facility's inaction in revising care plans, conducting new assessments, and ensuring the implementation of safety interventions for both residents led to a finding of immediate jeopardy. The lack of supervision and failure to enforce policies regarding smoking and elopement prevention created a situation where residents, including those with physical and cognitive limitations, were exposed to significant safety risks. Documentation and communication lapses further contributed to the ongoing deficiencies.
Removal Plan
- Remove smoking materials from R19's room and store them in a locked area.
- Reeducate R19 and have R19 sign the facility's smoking policy and behavior contract for smoking.
- Place R19 on checks to ensure smoking materials are not found in R19's room.
- Revise R19's care plan to reflect R19's current smoking plan.
- Update the facility's smoking policy to include information on where smoking materials will be kept to maintain safety and reduce the risk of unsafe smoking.
- Educate residents who smoke on the facility's smoking policy, review the designated smoking area, and collect all smoking materials for safe storage.
- Educate staff on the facility's smoking policy and procedure.
- Initiate audits to ensure all smoking materials remain locked and the smoking policy is being followed.
- Place a WanderGuard on R27 and review R27's order to ensure staff check placement, location, and function.
- Place R27 on checks to monitor R27's location and ensure safety.
- Secure the window in R27's room.
- Revise R27's care plan with updated interventions.
- Review residents at risk for elopement to ensure interventions are appropriate and in place.
- Educate staff on the facility's elopement policy and the importance of monitoring for exit seeking behavior.
- Educate staff on the importance of checking for WanderGuard placement and function.
- Review the facility's elopement policy to ensure information is included regarding what to do when a resident removes a WanderGuard.
- Initiate audits to ensure WanderGuards are in place and functioning properly.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Three residents receiving intravenous (IV) antibiotics experienced significant medication errors due to failures in medication order clarification, unauthorized changes to physician orders, and missed doses. One resident was admitted with a complex medical history including osteomyelitis, bacteremia, and acute kidney injury, and had a hospital discharge order for IV cefepime. Staff did not recognize a dosing error in the discharge order and entered it incorrectly into the facility's system. Subsequently, a registered nurse changed the order without consulting a physician, resulting in discrepancies between the hospital discharge order, the facility physician's order, and the nurse's revised order. The resident missed three doses of IV antibiotics over four days, and there was no documentation that the physician was notified of these missed doses. Another resident with multiple chronic conditions, including pneumonia, MRSA infection, and diabetic foot ulcer, had a physician order for IV vancomycin. The medication administration record (MAR) showed that a scheduled dose was not administered, and there was no documentation that the physician was notified of the missed dose. Additionally, a change in the administration time was communicated to the infectious disease office, but subsequent missed doses were not reported to the physician. A third resident with diagnoses including bacteremia, osteomyelitis, and diabetes was prescribed IV ceftriaxone via a PICC line. The MAR indicated that a scheduled dose was not administered because the resident was away from the facility for a physician appointment. There was no documentation that the physician was notified of the missed dose, and the facility physician confirmed that they were not made aware of the missed administration. In all cases, the facility failed to ensure that IV antibiotics were administered as ordered and that physicians were notified when doses were missed.
Removal Plan
- Review R203's medication orders for accuracy and availability and notify Infectious Disease (ID) of missed doses.
- Audit all residents on antibiotics and verify their medications are available and being administered.
- Educate nursing staff on the facility's policy for administering medication per physician orders and what to do when medications are unavailable.
- Educate nursing staff on confirming pharmacy orders with the physician and that nurses may not change medication orders without physician approval.
- Initiate audits to ensure admission orders are transcribed correctly and have been received from the pharmacy.
Deficient Sanitary Practices in Food Preparation and Dishwashing
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, as evidenced by multiple breaches in hand hygiene, improper monitoring of sanitizing solutions, and inadequate dishwashing practices. During an active Norovirus outbreak affecting both staff and residents, kitchen staff were observed not following proper handwashing protocols. Specifically, a staff member washed hands in a bucket of dirty water containing used silverware and then wiped hands with a cloth, rather than using the designated handwashing sink. Another staff member admitted to forgetting to wash hands after handling dirty dishes and before handling clean items. The facility was unable to provide a kitchen-specific hand hygiene policy when requested, instead providing a policy intended for nursing staff. Sanitizing solutions used in the kitchen were not properly tested or logged for effectiveness. Staff did not test the sanitizer buckets for the required parts per million (PPM) concentration or temperature, and there was no log maintained for these checks. Although the three-compartment sink was tested, the sanitizer buckets, which were used for cleaning surfaces and utensils, were not. Staff and the Dietary Manager confirmed that testing and logging of sanitizer buckets was not being performed as required by the FDA Food Code and manufacturer instructions. Dishwasher temperatures were not accurately monitored or maintained. The dishwashing machine's temperature gauge was known to be faulty, and staff relied on paper test strips that only indicated if the temperature was above 180°F, without providing an exact reading. Staff admitted to recording inaccurate temperatures on logs, and the Dietary Manager was aware that the logs did not reflect actual temperatures. The dishwashing machine consistently failed to reach the required sanitizing temperature, and this issue had been ongoing, as documented in previous reports and discussed in Quality Assurance meetings. Additionally, staff were observed moving from handling dirty dishes to clean dishes without changing aprons or washing hands, further compromising sanitary practices.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in following established protocols during a gastrointestinal (GI) illness outbreak and in the management of multidrug-resistant organisms (MDROs). The outbreak line lists for both staff and residents were incomplete, lacking critical information such as the date and time of last symptoms, which is necessary to determine the appropriate duration for contact precautions and staff exclusion from work. As a result, two residents were removed from contact precautions prematurely, contrary to facility policy, and the County Health Department was not updated on new cases as required. Additionally, discrepancies existed between the staff illness line list and the human resources call-in list, further complicating outbreak management. Staff did not consistently adhere to infection control protocols related to enhanced barrier precautions (EBP) and contact precautions. For example, an LPN failed to wear a gown while manipulating a resident's clothing to administer a pain patch, despite the resident being on EBP for MDRO colonization. Staff also entered a resident's room on contact precautions without donning personal protective equipment (PPE), and soiled linens were transported through hallways without being properly bagged, increasing the risk of cross-contamination. Furthermore, staff did not sanitize shared equipment, such as a mechanical lift, after use with a resident on EBP, and hand hygiene was not offered to residents before or after meals during an active Norovirus outbreak. Observations and interviews revealed a lack of understanding and inconsistent application of infection control policies among staff, including the handling of soiled linens, use of PPE, and adherence to hand hygiene protocols. Residents with cognitive impairments and those responsible for their own healthcare decisions were affected by these lapses. The facility's own policies, which align with state and federal regulations and national guidelines, were not followed, resulting in practices that had the potential to affect all residents in the facility.
Insufficient Nursing Staff Resulting in Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews, staff interviews, observations, and record reviews. Several residents reported excessive wait times for call light responses, with some waiting up to three hours for assistance with toileting and other needs. One resident, who takes a diuretic, reported being unable to use a urinal for up to three hours, while another resident with a recent above-the-knee amputation described being left in a wet bed and not receiving timely toileting assistance. Additional residents reported being told to soil themselves due to lack of available staff, and one resident experienced incontinence and humiliation after waiting an hour and a half for help during a diarrhea episode. Observations in the dining room revealed that only one CNA was present to assist seven residents during breakfast, resulting in delays in feeding assistance and residents receiving cold food. Two residents who required feeding assistance had to wait until all other residents were served, and another resident repeatedly requested water but did not receive it because the CNA was occupied. The CNA confirmed that staffing was insufficient in the dining room, as CNAs were required to cover both the dining room and resident units, leading to delays in care and unmet needs. A review of the facility's staffing schedules and Facility Assessment showed that staffing levels frequently fell below the recommended ratios based on resident acuity and census. On several occasions, there were only two staff members (one CNA and one LPN) available for over 50 residents during the night shift, resulting in staffing hour ratios as low as 2.51, which was below the facility's own assessment guidelines. The Nursing Home Administrator acknowledged that staffing levels were not consistently maintained according to the facility's assessment and resident needs.
Medication Storage, Labeling, and Security Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. Medication carts in the B wing and near the nurses' station were found unlocked and unattended, with one cart displaying resident information on an open computer screen facing the hallway. Staff interviews confirmed that medication carts should be locked when not attended and that resident information should not be left visible. Additionally, several medication cards, including schedule two narcotics, were found unsecured in an unlocked desk drawer at the nurses' station, rather than in a locked area as required by facility policy. Staff acknowledged that these medications had been delivered from the pharmacy and should have been secured until counted at shift change. Further deficiencies were identified in the E wing medication cart, which contained multiple medications that were open and undated, including insulin vials, artificial tears, inhalers, and nasal sprays. Some medications lacked resident names, and at least one bottle of vitamin C was expired. Staff confirmed that these medications were not labeled or dated appropriately and that expired medications were present. The D wing medication storage room also contained numerous expired medical supplies and medications, as well as an unlabeled pill container with unknown contents and no resident identification. Facility policies reviewed by surveyors required that all drugs and biologicals be stored in locked compartments, with controlled substances in separately locked areas, and that medications be properly labeled and dated. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the observed practices did not align with facility protocols, as medications and resident information were not properly secured, and expired or unlabeled items were not removed from storage.
Failure to Provide Timely and Documented Wound Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate wound care and timely skin assessments for two residents, resulting in deficiencies related to wound management. One resident was admitted with multiple wounds, including ulcers and abrasions, and had a history of sepsis and diabetes. Despite clear documentation from the hospital and an advanced practice nurse indicating the need for wound care, the facility did not complete a timely or accurate skin assessment upon admission. Wound care orders were not obtained until several days after admission, and the resident did not receive any wound care during their stay. The treatment administration record did not align with the actual wounds present, and there was a lack of documentation for certain wounds requiring care. Another resident had a sore on the left lower shin, which was observed to have a dressing that was not initialed or dated. The medical record did not contain an order for this dressing, nor did it document the presence of a wound on the left lower shin. Skin checks in the record failed to note any skin impairments, and the wound was not included on the wound boards for review. The wound care nurse confirmed there was no documentation or treatment order for the area until after the issue was brought to attention during the survey. Interviews with staff and residents confirmed that wound care was either not provided or not documented as required. The facility's policy required verification of physician orders and documentation of dressing changes, but these steps were not consistently followed. The lack of timely assessment, absence of treatment orders, and failure to document wound care contributed to the deficiencies identified during the survey.
Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
A resident was admitted to the facility with a history of sepsis, type 2 diabetes, and an existing pressure injury on the right buttock. Upon admission, the resident was assessed as being at risk for pressure injuries, and hospital records indicated the presence of a pressure injury prior to arrival. Despite this, the facility did not complete a thorough or timely skin assessment, as the initial skin map failed to document any skin issues, and the wound evaluation did not accurately reflect all existing wounds. The care plan was updated to include interventions such as a pressure-relieving air mattress and turning/positioning, but it did not specifically address all identified wounds, including a pressure injury on the right hip. Orders for wound care were not obtained until several days after admission, and there was confusion among staff regarding the documentation and location of the wounds. The resident reported that wound care was not provided during their stay, and staff confirmed that no wound care was administered due to the lack of timely physician orders. Interviews with facility leadership and nursing staff revealed that the required skin assessments were not completed within the expected timeframe, and there was a lack of clarity regarding the number and location of the resident's pressure injuries. The facility was unable to provide evidence of comprehensive wound assessment or care during the resident's stay, resulting in a failure to provide necessary care and services to promote healing and prevent the development of new pressure injuries.
Failure to Follow Activated POAHC and Notify Resident Representative
Penalty
Summary
The facility failed to ensure that an activated Power of Attorney for Healthcare (POAHC) was properly recognized and followed for one resident. The resident, who had diagnoses including depression, malnutrition, type two diabetes, and obstructive uropathy, was admitted with an activated POAHC after returning from a hospital stay for urinary sepsis. Despite a Statement of Incapacity signed by two medical providers and included in the hospital discharge paperwork, the facility allowed the resident to sign multiple consent forms upon readmission, treating the resident as their own decision maker. The POAHC was not notified of the activation until a later date, and staff interviews revealed a lack of awareness and understanding regarding the resident's capacity status and the proper procedures for reviewing advance directive paperwork during admission. Staff responsible for the resident's admission and care, including the LPN, Social Services Director, and Medical Records Nurse, demonstrated inconsistent knowledge and communication regarding the resident's POAHC status. The LPN confirmed that the POAHC should sign consents if activated but was unsure about reevaluation procedures for capacity. The Social Services Director and POAHC were both unaware of the activation at the time of care planning discussions. The Medical Records Nurse only discovered the Statement of Incapacity when scanning hospital discharge paperwork and subsequently notified the LPN. This series of oversights resulted in the resident's representative not being given the opportunity to exercise the resident's rights as required.
Failure to Complete PASRR Requirements for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) requirements were met for two residents with mental illness who were admitted under a 30-day hospital discharge exemption. For one resident with a diagnosis of bipolar disorder and moderate cognitive impairment, the medical record included a PASRR Level I Screen indicating a major mental disorder and a 30-day exemption, but did not contain the required County form F-20822 or a PASRR Level II Screen. The Social Services Director reported submitting the exemption request but did not receive confirmation, and the Level II Screen was only submitted after the surveyor's inquiry. Similarly, another resident with adjustment disorder and depression, who was receiving duloxetine, had a PASRR Level I Screen indicating mental illness and a 30-day exemption, but the medical record lacked both the required exemption form and a PASRR Level II Screen. The Social Services Director also stated that the exemption request was submitted without confirmation and the Level II Screen was not obtained until prompted by the surveyor. These omissions resulted in the facility not meeting federal and state PASRR requirements for residents with mental illness.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with congestive heart failure received timely physician visits as required by federal and state regulations. The facility's policy mandates that residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with the option for alternating visits by a physician extender after the initial visit. Record review showed that the resident was seen by a physician in late November and December, and by a nurse practitioner in January, February, and March. However, there was no documentation of a physician visit in February, as required by the alternating schedule. Interviews with the Nursing Home Administrator revealed that the physician attempted to see the resident on two occasions in January, but the resident was not present due to attending dialysis appointments. The administrator provided a hand-written note indicating attempted visits, but confirmed that only completed visits are documented in the medical record system, and there was no physician visit note available for February. The lack of documentation and absence of a physician visit in February led to the deficiency.
Failure to Ensure Proper Medication Orders and Assessments for Bedside Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents by not ensuring proper physician orders and assessments for self-administration and bedside storage of medications. One resident was observed with melatonin gummies at the bedside without a physician order or a documented self-administration assessment. This resident also did not receive prescribed bedtime medications on a specific date, and there was no documentation that the physician was notified of the missed doses. The resident had intact cognition and made their own medical decisions, but the required processes for self-administration and bedside medication storage were not followed. Another resident was found with a bottle of bovine collagen pills, liquid Imodium, and two albuterol inhalers at the bedside. While the care plan and assessments allowed for self-administration of certain medications, there was no physician order or assessment permitting the resident to keep Imodium at the bedside or to self-administer it. The resident had intact cognition, and the care plan specified which medications could be self-administered, but Imodium was not included among them. A third resident was observed with triamcinolone cream, lidocaine ointment, and elderberry immune health pills at the bedside. The medical record did not contain a physician order or self-administration assessment for these medications to be kept at the bedside. The resident had intact cognition, and the care plan and assessments addressed self-administration for some medications, but not for all those found at the bedside. The facility's policies require physician orders and interdisciplinary team assessments for self-administration and bedside storage, which were not completed for these medications.
Failure to Administer Vaccines After Consent
Penalty
Summary
The facility failed to ensure that two residents received influenza or pneumococcal vaccines as indicated by their consent and eligibility. One resident, who had moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), was admitted with a diagnosis of Parkinson's disease. The POAHC provided verbal consent for the resident to receive the influenza vaccine, as documented on the Vaccine Administration Record-Immunization Consent Form. However, the medical record did not show that the influenza vaccine was administered to this resident. Another resident, who was cognitively intact and responsible for their own healthcare decisions, was admitted with a diagnosis of congestive heart failure. This resident signed an Authorization and Release form consenting to receive a pneumococcal vaccine. Despite this, the medical record did not indicate that the pneumococcal vaccine was administered. In both cases, the Infection Preventionist confirmed during interviews that the residents should have received the respective vaccines but did not.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15, was admitted to the facility with an activated Power of Attorney for Healthcare (POAHC) responsible for healthcare decisions. The POAHC provided signed consent for the resident to receive a COVID-19 vaccine, as documented in an undated Authorization and Release for COVID-19 Vaccine form. Despite this consent, the facility did not administer the COVID-19 vaccine to the resident, and there was no documentation in the medical record indicating that the vaccine was given. During an interview, the Infection Preventionist confirmed that the resident should have received the vaccine but did not.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide required annual training on its Quality Assurance and Performance Improvement (QAPI) program to staff, including several Certified Nursing Assistants (CNAs). The facility's QAPI plan specifies that all employees, departments, and services are to be included in the program, and that leadership is responsible for ensuring staff receive necessary technical training. Upon review of staff education records, it was found that the education provided to selected CNAs did not include QAPI program education. The Nursing Home Administrator confirmed that these staff members had not received the required QAPI training, despite the expectation that they should have.
Delayed Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to a medical record for a resident, identified as R2, who requested a copy of their medical record in writing on January 3, 2025. According to the facility's Medical Records policy, a copy should be provided within 7 working days. However, R2's medical record was not mailed until January 28, 2025, which was 25 days after the request. This delay was not in accordance with the facility's policy. R2, who was responsible for their healthcare decisions and had a BIMS score indicating no cognitive impairment, was discharged from the facility on January 6, 2025. During the survey, the Medical Records Coordinator (MRC-C) confirmed the delay and stated that the facility does not have a designated timeframe for fulfilling records requests, which can take a month or more due to the volume of records and the need for administrative review. The Nursing Home Administrator (NHA-A) believed that records requests should be fulfilled within 10 days, indicating a lack of clarity and adherence to the facility's policy. The deficiency was identified through staff interviews and record reviews, highlighting a failure in the facility's process for handling medical record requests.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in deficiencies observed in the care of two residents. Resident 5, who had a suprapubic catheter and was on enhanced barrier precautions (EBP), did not receive appropriate care as Certified Nursing Assistant (CNA)-D did not wear a gown during high-contact care activities. This was despite the presence of an EBP sign outside the resident's room, which should have prompted the use of additional personal protective equipment (PPE) such as gowns. The Director of Nursing (DON) and the Infection Preventionist (IP) confirmed that CNA-D should have worn a gown during these care activities. Similarly, Resident 6, who had multiple diagnoses including peripheral vascular disease and was a carrier of carbapenem-resistant Acinetobacter baumannii, was also on EBP. During a bed bath, CNA-E failed to perform proper hand hygiene and glove changes when applying barrier cream after cleaning the resident's peri-area. This lapse in infection control practices was acknowledged by both the DON and the IP, who agreed that CNA-E should have removed gloves, completed hand hygiene, and donned new gloves before applying the cream.
Failure in Monitoring and Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring and administration of psychotropic medication for a resident diagnosed with Parkinson's disease, anxiety, hallucinations, and malnutrition. The resident had an order for clozapine, a medication for psychosis, which required weekly monitoring through a complete blood count (CBC) with differential. On a specified date, the facility staff incorrectly ordered a CBC without differential, leading to the resident missing eight doses of clozapine over several days. This lapse in medication administration resulted in the resident experiencing symptoms of psychosis, including standing on their bed, attempting to ingest non-food items, and exhibiting excessive drooling and frothing from the mouth. The deficiency was further compounded by the lack of awareness and education among the nursing staff regarding the specific lab requirements for clozapine monitoring. Interviews with various staff members, including registered nurses and a consultant pharmacist, confirmed that the incorrect lab draw and subsequent missed doses of clozapine significantly increased the likelihood of the resident's psychosis symptoms. The resident was eventually sent to the emergency room for treatment and returned to the facility after receiving care. The facility's failure to adhere to the physician's orders for lab monitoring and medication administration directly contributed to the resident's adverse health event.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed care and unmet needs. Residents reported significant delays in response to call lights, with some waiting over an hour for assistance. This delay in care led to instances of incontinence and missed medications, as residents were unable to receive timely help for toileting and pain management. The facility's staffing plan indicated a range of licensed nursing and nurse aides required, but observations and interviews revealed that these staffing levels were not consistently met, particularly during night shifts. Residents with various medical conditions, including chronic pulmonary edema, diabetes, and cerebrovascular accidents, were affected by the staffing shortages. These residents, who were not cognitively impaired, expressed frustration over the lack of timely care. For instance, one resident reported waiting over an hour for call light responses, leading to incontinence, while another resident experienced delays in receiving pain medication, resulting in prolonged discomfort. Staff interviews corroborated these accounts, highlighting the challenges faced due to insufficient staffing, such as the inability to complete scheduled tasks and the need to pass tasks to subsequent shifts. Staff members, including CNAs and LPNs, reported being overwhelmed by the workload, with some shifts staffed by only one CNA per wing. Agency staff frequently failed to show up or left mid-shift, exacerbating the staffing issues. Despite these challenges, management reportedly denied any staffing concerns and claimed that there was always a nurse available to assist. However, the lack of a call light log and the consistent reports of delayed care suggest that the facility did not adequately address the staffing deficiencies, impacting the quality of care provided to residents.
Failure to Notify Neurologist of Missed Clozapine Doses
Penalty
Summary
The facility failed to notify a neurologist when a resident did not receive their prescribed medication, clozapine, for four consecutive days. This medication is an antipsychotic used to treat psychosis related to Parkinson's disease. The resident, who had diagnoses including Parkinson's disease, anxiety, hallucinations, and malnutrition, was admitted to the facility with a moderately impaired cognition as indicated by a BIMS score of 12 out of 15. The facility's policy required consultation with a resident's physician within 24 to 48 hours when there is a significant alteration to a resident's treatment, but this was not followed. The resident missed a total of eight doses of clozapine from November 23 to November 26, 2024, and was subsequently hospitalized for increased behavioral symptoms, including attempting to ingest lotion. During an interview, a neurology RN confirmed that the neurologist was not informed about the missed doses of clozapine, which is a highly monitored medication. The failure to notify the neurologist about the missed medication doses led to the resident's hospitalization due to exacerbated psychosis symptoms.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate care and treatment for three residents, leading to deficiencies in their care. One resident with Parkinson's disease and a deep brain stimulator (DBS) did not receive proper device management. The staff failed to apply or charge the DBS as ordered, and the resident was observed without the charging neck sling on multiple occasions. The facility's staff, including the Nursing Home Administrator and Director of Nursing, were unaware of the DBS's remote control function, and there was no evidence of staff education on the device's use. This lack of proper management could exacerbate the resident's Parkinson's symptoms. Another resident with dementia and a history of intimate relationships experienced a significant change in condition, including a decline in cognitive function. Despite this, the facility did not update the resident's intimacy assessment or care plan to reflect the change. The resident's interactions with another resident were not adequately monitored, and staff were unclear about the appropriate actions to take. The facility's policy required reassessment of consent capacity with any condition changes, but this was not followed, leading to confusion and potential issues with consent. A third resident with a diagnosis of fungal candidiasis did not receive oral care as outlined in their care plan. The care plan specified the use of a toothette with toothpaste and mouthwash, but staff only used water for oral care. This deviation from the care plan raised concerns about the effectiveness of the treatment for the resident's recurring thrush. The Director of Nursing was unaware that the care plan was not being followed, indicating a lack of oversight and communication within the facility.
Deficiencies in Resident Safety and Staff Training
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, leading to a fall incident involving a resident. The resident, who had a history of cerebral infarction, polyneuropathy, and hemiplegia, was assessed to require a full body (Hoyer) lift with the assistance of two staff members for transfers. However, on the day of the incident, a CNA did not adhere to the care plan and attempted to transfer the resident using a sit-to-stand lift, resulting in the resident feeling weak and subsequently falling. The facility's fall policy mandates that all residents receive adequate supervision and assistance to prevent falls, but this was not followed in this case. Additionally, the facility did not provide timely staff education on safe transfer techniques. Although transfer education was conducted, the attendance record showed that 15 CNAs did not receive the training initially. The Nursing Home Administrator confirmed that the Director of Nursing was still working on completing the staff education related to safe transfers and adherence to care plans. This lack of comprehensive training contributed to the unsafe transfer practices that led to the resident's fall. Furthermore, the facility was found to have safety hazards related to the charging of motorized wheelchair batteries in a vacant resident room. The room lacked proper ventilation and was used for storage, including flammable materials, without a door closure. The chargers used for the batteries had warnings about explosive gases and the need for adequate ventilation, which was not provided. This created a potential fire hazard, as confirmed by the Life Safety Consultant, who noted the absence of ventilation and the need for a door closer due to the storage of boxes in the room.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure accurate administration of medication for two residents, R4 and R10, as identified during a survey. R4 received multiple scheduled medications late over several days in December 2024 and January 2025. These medications included Vitamin C, Apixaban, Duloxetine, Guaifenesin, Lactobacillus Probiotic, Magnesium Oxide, Metformin, Norethindrone Acetate, Sulfamethoxazole-Trimethoprim, Ropinirole, Metoprolol Tartrate, Buspirone, Ursodiol, Gabapentin, Topiramate, and Gabapentin Capsule. The Director of Nursing confirmed that the facility's policy allows for medication administration within one hour before or after the scheduled time, and acknowledged that the medications were administered outside this timeframe. R10 experienced a failure in receiving scheduled pain medication on the night shift of January 13, 2025. Despite having a physician's order for Tramadol to be administered every six hours, R10 did not receive the midnight dose, resulting in increased pain levels. The Assistant Director of Nursing confirmed that the dose was not administered because it was deemed too close to the next scheduled dose. R10 expressed frustration over the lack of timely pain management and reported that staff were overworked, leading to communication breakdowns regarding medication needs. Additionally, R10's medications were left unsupervised by LPN-L, who did not ensure that R10 took the medication. This occurred despite R10 not having a self-administration assessment or order. R10 expressed concerns about the potential for medication misuse, as nurses would leave medication without observing its consumption. The Nursing Home Administrator confirmed that R10 should not have been left with medication unsupervised, as there was no assessment or order permitting self-administration.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act, for one resident. On a specific date, a Certified Nursing Assistant (CNA) reported an allegation of verbal abuse involving another CNA and a resident with severe cognitive impairment. The resident had a history of unspecified intracranial injury with loss of consciousness and nontraumatic subarachnoid hemorrhage. Despite the report of abuse being made to the administration and an investigation being initiated, the facility did not report the allegation to local law enforcement as required by their policy. The facility's undated Abuse policy mandates contacting local law enforcement when there is a reasonable suspicion of a crime. However, in this case, the Nursing Home Administrator did not notify law enforcement, despite typically doing so for abuse allegations. The incident involved a CNA allegedly using abusive language towards a resident, which was witnessed by another CNA. The accused CNA was suspended and later returned to work after completing education on abuse, effective communication, and managing difficult behaviors. The failure to report the incident to law enforcement was noted as a deficiency during the surveyor's review.
Failure to Respond to Resident's Change of Condition
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, R2, who experienced a significant change in condition. On 5/16/24, R2 reported difficulty breathing and feeling like they were having a stroke. Despite these serious symptoms, the nursing staff, including RN-C and LPN-K, did not adequately assess R2 or report the concerns to a physician. Additionally, the change in condition was not communicated to the night shift staff, leading to a lack of continuous monitoring and care. R2 had a history of chronic respiratory failure, hypertension, and anxiety, among other conditions, and was known to have increased anxiety when unable to clear secretions from their trach. On the morning of 5/16/24, CNA-D noticed R2 was incontinent, pale, and weaker than usual, and reported these observations to RN-C multiple times. However, RN-C did not respond appropriately, and there was no documentation of any assessment or vital signs after 5/15/24. Other staff members, including CNA-J and LPN-K, also noted R2's distress but failed to take adequate action. The lack of proper assessment and communication resulted in R2's condition deteriorating without appropriate medical intervention. R2 was found unresponsive and pronounced dead on 5/17/24 due to diastolic congestive heart failure. The facility's failure to adhere to the Wisconsin Nurse Practice Act and its own policies on change of condition led to a finding of immediate jeopardy, highlighting the serious nature of the deficiency.
Removal Plan
- Educate nursing staff on change of condition policies and procedures, how to conduct a physical head-to-toe assessment, completing change of condition documentation, family and provider notification, and a change of condition form.
- Initiate monitoring of nursing and CNA shift-to-shift reports.
- Complete a change of condition audit and initiate shift change audits.
- Hold a quality assurance performance improvement (QAPI) meeting with the Medical Director to discuss the event and corrective measures to be taken.
Incompetent Staff Assigned to Resident Care Tasks
Penalty
Summary
The facility failed to ensure that competent staff performed nail care for a resident, identified as R3, who was part of a sample of nine residents. R3 had a history of aneurysm, anxiety, malnutrition, depression, and dementia, and was prescribed warfarin sodium, an anticoagulant medication. Despite these conditions, Hospitality Aide (HA)-E, who was not a certified nurse aide, was asked by Registered Nurse (RN)-C to trim R3's nails. HA-E confirmed performing the task but ceased after realizing the lack of qualification for such duties. The Director of Nursing (DON)-B confirmed that HAs were not supposed to trim residents' nails. Additionally, the facility did not ensure that competent staff completed vital signs for multiple residents. HA-E and HA-L, who were not enrolled in a Certified Nursing Assistant (CNA) course, were asked by RN-C to take vital signs. HA-E expressed confusion about this task, as HA-E had no CNA training. Interviews with other staff, including CNA-D, RN-H, and CNA-I, revealed inconsistencies in the delegation of vital signs, with some staff indicating that only CNAs should take regular vital signs, while others noted that HAs were improperly tasked with this responsibility. The surveyor's review of HA sign-off sheets for vital signs showed that HA-L and HA-E were signed off by RN-C, but both required more training, particularly in manual blood pressures. No follow-up or re-evaluation was conducted. The DON-B acknowledged that RN-C had been reprimanded for not documenting proper assessments and had been written up for similar concerns. This lack of proper training and oversight led to the deficiency in ensuring competent staff performed necessary resident care tasks.
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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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