Avina On Division
Inspection history, citations, penalties and survey trends for this long-term care facility in Fond Du Lac, Wisconsin.
- Location
- 517 E Division St, Fond Du Lac, Wisconsin 54935
- CMS Provider Number
- 525522
- Inspections on file
- 27
- Latest survey
- March 28, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Avina On Division during CMS and state inspections, most recent first.
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.
Administration failed to ensure a DON was employed, did not maintain required RN coverage, and did not provide sufficient staffing, despite being responsible for recruiting competent leadership and ensuring adequate licensed and non-licensed staff. After the last DON left, there was no RN on staff, including most weekends, and there was no documented evidence that DONs from sister facilities who were said to be helping were actually present. A CMA/MT had been assessing pain and administering PRN narcotic pain medications, which leadership confirmed was outside that role’s scope of practice. A resident reported long delays in call light response, another reported that staff left the halls during mealtimes, and an LPN stated residents needed more attention than staff could provide. These failures resulted in Immediate Jeopardy under nursing services and were cited under F727, F658, and F725.
A cognitively intact resident with multiple chronic conditions, including COPD and chronic myeloid leukemia, was care planned to be encouraged to use the toilet for bowel evacuation, but staff followed Kardex instructions to use a bedpan and at times only placed incontinence pads under her instead. The resident reported to police that she had been left sitting in her bowel movement for several hours and that staff used chucks instead of a bedpan, causing discomfort and embarrassment. In interviews, she stated she preferred to be transferred with a lift to the toilet and had recently tolerated a sit-to-stand lift well. An LPN acknowledged miscommunication between shifts that led to the resident not receiving needed care and stated that residents required more attention than staff could provide, demonstrating a failure to provide dignified, care-planned toileting consistent with the resident’s preferences.
Surveyors found that kitchen equipment and dishware used to serve residents had visible white residue, making it difficult to determine cleanliness. Staff attributed the issue to a lack of water softener salt, which had persisted for months due to a billing issue with the supplier. Dietary staff and residents expressed concern and dissatisfaction with the appearance and cleanliness of the dishware, and some staff brought their own items from home.
Surveyors found that outside garbage containers were left uncovered and contained both bagged and loose, unbagged garbage and debris, contrary to facility policy. Staff confirmed that the containers were routinely left uncovered and sometimes contained loose refuse, with no lids available for use. This practice had the potential to affect all residents in the facility.
Staff failed to follow infection control protocols, including an LPN administering medication to a resident on contact precautions without proper PPE and a laundry aide transporting uncovered clean clothing through hallways. Clean linens were also moved through dirty areas, and soiled linen was found in clean areas, contrary to facility policy and CDC guidelines.
A resident with hemiplegia and hemiparesis, requiring substantial assistance for mobility, was unable to access the call light while in bed due to it being placed out of reach under a pillow. The resident, who had intact cognition, was unable to request help for repositioning until staff were notified by a surveyor. Staff confirmed the call light was not accessible, which was not in accordance with facility policy.
Two residents with intact cognition did not receive accurate medication administration. In both cases, staff left medications at the bedside without returning to verify consumption, yet documented the medications as given. Neither resident had a current self-administration assessment as required by facility policy, and one resident had expired OTC medications at the bedside. Staff interviews confirmed that policies for medication observation and assessment were not followed.
The facility did not ensure proper disposal of garbage and refuse, as observed by a surveyor and the NHA. Two outside garbage receptacles were found with open lids, which were routinely left open during the AM shift due to their height. Maintenance staff closed them in the evening. A neighbor had complained about the issue, and an anonymous person confirmed the lids were often left open, causing a foul smell.
The facility did not have a qualified food and nutrition services director, as the Dietary Manager had not completed the necessary certification or education and lacked prior experience. Additionally, the facility did not have a full-time dietitian onsite, potentially affecting all 31 residents.
The facility failed to ensure food was stored and prepared safely, with issues including a slimy ice machine filter, dirty microwaves, undated food items, and missing temperature and sanitizer logs, potentially affecting all 31 residents.
The facility failed to meet PASRR requirements for four residents, including timely completion of Level I and Level II Screens and obtaining county exemptions. Staff interviews revealed a lack of adherence to PASRR protocols and proper documentation.
The facility admitted two residents for long-term care despite their POAHC paperwork indicating they did not want to be admitted to a nursing home. Both residents had severe cognitive impairment and no active discharge plans. The social worker acknowledged the need for court intervention based on the POAHC documents.
The facility failed to notify a physician and the POAHC of a resident's injury, resulting in a lack of documentation and communication. The resident had severe cognitive impairment and was receiving hospice services. Staff observed a bump and bruise on the resident's head, but there was no record of notification or follow-up documentation.
The facility failed to accurately code MDS 3.0 assessments for two residents. One resident's smoking status was not recorded despite having a smoking care plan and being observed smoking. Another resident's use of a CPAP machine was not documented in their MDS assessment, despite having a physician order for CPAP therapy and a CPAP machine in their room. The MDSC acknowledged both oversights.
The facility failed to ensure that smoking materials were safely stored for a resident with severely impaired cognition. Despite the care plan's intervention, cigarettes and a lighter were repeatedly found on the resident's bedside table, contrary to facility policy and staff statements.
A resident was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not care planned, assessed, or monitored. The CPAP machine was observed without proper labeling, and staff confirmed the lack of an order and cleaning schedule. The resident indicated the machine had not been cleaned since admission.
A resident's food preferences were not honored, as they were repeatedly served items against their stated preferences, including mashed potatoes with gravy and pureed eggs, despite clear instructions and multiple complaints.
A resident with Alzheimer's disease and severely impaired cognition sustained a bump and bruise on the head, but the medical record lacked documentation regarding the injury, notifications, follow-up, assessments, and care plan updates. A Risk Management Report described the incident and indicated notifications were made, but this information was not included in the medical record.
A facility failed to maintain an infection control program when a CNA did not follow proper hand hygiene procedures during peri and Foley care for a resident with a history of MRSA and CRE. The CNA did not sanitize hands after glove removal and before donning new gloves, even while providing care near an open wound.
The facility did not retain daily nurse staffing data for the required minimum 18 months. A surveyor's review and interviews with the Nursing Home Administrator revealed that the night nurse did not save the nurse staffing postings as required.
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.
Failure of Administration to Ensure DON, RN Coverage, Scope Compliance, and Adequate Staffing
Penalty
Summary
The deficiency involves the Administrator’s failure to ensure appropriate nursing leadership, RN coverage, and staffing, as required by the Administrator job description and federal regulations. The Administrator’s job description states they are responsible for directing day-to-day facility functions in accordance with applicable regulations, recruiting competent department directors, and ensuring adequate trained licensed and non-licensed personnel are on duty at all times. Despite this, the facility had no Director of Nursing (DON) after the last DON’s final day on 03/13/26, which was confirmed by both the Administrator and the Regional Director of Operations (RDO). The RDO reported that DONs from sister facilities were helping, but there was no documented evidence of their presence. The Assistant Director of Nursing (ADON) confirmed the facility had not had an RN on staff since the former DON left on 03/13/26 and that, even when the former DON was present, there was no RN coverage for most weekends. Surveyors determined that Administration was aware there was no qualified DON overseeing resident care since 03/13/26 and that there was not an RN in the building for a minimum of 8 hours a day, 7 days a week. The facility also failed to ensure that staff worked within their scope of practice and that staffing levels were sufficient to meet residents’ needs. Clinical record review for one resident (R2) showed that a Certified Medication Aide/Medication Technician (CMA/MT1) assessed pain levels, administered PRN narcotic pain medications, and reassessed pain, and CMA/MT1 confirmed she had been performing these assessments and administering PRN narcotics throughout her employment. The Vice President of Clinical Operations stated that it was not within a CMA/MT’s scope of practice to assess pain or administer PRN pain medications. A local police narrative documented that the Administrator told an officer that one resident needed constant care and that it was very difficult to provide that level of care due to lack of staffing. One resident reported that call lights took 30–45 minutes to be answered, another resident reported that during mealtimes all staff went to the dining room leaving no staff on the halls, and an LPN stated residents needed more attention than staff could provide. The survey identified these failures under F727 (nursing services and RN/DON requirements), F658 (services within scope of practice), and F725 (sufficient staffing), and Immediate Jeopardy was cited under §483.35 Nursing Services related to facility administration.
Failure to Provide Dignified, Care-Planned Toileting for a Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to dignity and to follow her care-planned toileting preferences. The facility’s dignity policy required staff to provide care in a manner that maintains or enhances each resident’s dignity and respects individual needs and choices. The resident, who had COPD, osteomyelitis of the lumbar vertebra, panlobular emphysema, and chronic myeloid leukemia, was cognitively intact with a BIMS score of 15 and was aware of when she needed a bowel movement. Her care plan for constipation related to opioid use included an intervention to encourage her to sit on the toilet to evacuate bowels if possible. However, the Kardex used by nursing staff directed that she required assistance by two staff using a bedpan for toileting, which was inconsistent with the care plan interventions. According to the police body worn camera narrative, officers responded to a complaint from the resident about lack of care. The resident reported that staff placed absorbent incontinence pads (chucks) under her instead of providing a bedpan and that she had been sitting in her bowel movement for quite some time, stating her chucks had last been changed over three hours earlier. During interviews, the resident stated that sometimes staff gave her a bedpan but other times only placed an incontinence pad underneath her, and that this was uncomfortable and embarrassing. She expressed a preference to be transferred with a lift to use the toilet and reported that a recent sit-to-stand lift transfer had worked well. An LPN confirmed there had been miscommunication that resulted in the resident not receiving the care she needed and stated that residents needed more attention than staff could provide. These actions and inactions resulted in the resident not being toileted in accordance with her care plan and preferences, and not being treated in a manner that maintained her dignity.
Kitchen Equipment and Dishware Not Free from Residue Accumulation
Penalty
Summary
The facility failed to ensure that kitchen equipment and dishware used to serve residents were free from visible residue accumulation, as observed during a kitchen tour and confirmed through staff interviews and record review. Food preparation equipment, including a food processor, pots, pans, and dishware, were found to have significant white or gray residue, making it difficult to determine if items were clean. The Dietary Manager acknowledged the residue, attributing it to a hard water issue that had persisted for at least two months due to the lack of salt for the water softener. Staff reported that while silverware was soaked in vinegar to improve appearance, they were unable to adequately clean plates, cups, bowls, and other equipment. Dietary staff interviewed during the survey expressed concern about the appearance and cleanliness of the dishware, with one aide stating that the residue made it hard to tell if items were clean and describing the condition of a coffee pot as "disgusting." Staff indicated that the issue had been ongoing and was embarrassing, with some staff choosing to bring dishware from home rather than use the facility's items. The Maintenance Director confirmed that a billing issue with the salt provider had prevented timely delivery of water softener pellets, resulting in the hard water residue. The director stated that the facility was unable to purchase the necessary quantity of salt independently and had been attempting to resolve the issue with the provider. Residents interviewed expressed uncertainty and dissatisfaction regarding the cleanliness of their cups and dishware, with some stating they did not know if the items were clean and others expressing skepticism or discomfort about using dishware with visible residue. The Nursing Home Administrator acknowledged that residents should have visibly clean dishes and equipment for food preparation. The accumulation of residue on food-contact surfaces and dishware was observed to affect all residents in the facility.
Improper Disposal and Storage of Garbage and Refuse
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse in accordance with its own policy. During an initial kitchen tour, two large rolling containers positioned outside the building were found to be uncovered, with one container full of bagged garbage and the other half full, containing both bagged and loose, unbagged garbage and debris such as food wrappers, food particles, unidentified matter, and paper coffee cups. There were no lids available to cover the containers, and staff interviews confirmed that the garbage in these containers was routinely left uncovered. Further observation revealed that the rolling containers were emptied only when full or on a daily basis by housekeeping staff, but loose garbage and debris were still present in the containers. Staff acknowledged that the containers should only contain bagged garbage and should be covered, as per facility policy, but this was not being followed. This deficiency had the potential to affect all 33 residents residing in the facility.
Failure to Maintain Infection Control and Proper Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in protocol. A resident on contact precautions was administered medication by an LPN who entered the resident's room without donning the required personal protective equipment (PPE). The LPN initially entered without any PPE, then donned only gloves after being prompted, and did not wear a gown during either medication administration, despite leaning against the resident's bed rail. The Director of Nursing confirmed that staff are expected to follow posted signs and wear both gown and gloves when entering rooms of residents on contact precautions. Additionally, the facility did not adhere to proper laundry handling procedures. A laundry aide was observed transporting clean clothing uncovered through hallways and delivering them to residents' rooms, stating that this was standard practice due to lack of appropriate carts or covers. Clean linens were also observed being moved from the clean side of the laundry room through the dirty side and into a housekeeping closet, and a soiled linen hamper was found in the clean area of the laundry room. The Director of Nursing confirmed that clean and soiled laundry should be kept separate at all times and that clean laundry should not cross into dirty areas.
Call Light Inaccessibility for Resident with Mobility Impairment
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and hemiparesis following a cerebral infarction, who required substantial to maximum assistance for mobility and had intact cognition, was found unable to access their call light while in bed. The facility's policy required that call lights be within reach of residents at all times. During an observation, the resident reported being unable to locate or reach the call light, which was found under the pillow on the side affected by their impairment. The resident expressed a need for assistance with repositioning but was unable to summon help due to the inaccessible call light. Staff were notified by the surveyor, and upon entering the room, a CNA confirmed that the call light was not within the resident's reach and handed it to the resident. The Director of Nursing later confirmed that the call light should have been accessible according to facility policy. The deficiency was identified based on direct observation, staff and resident interviews, and review of the facility's policy and the resident's medical record.
Failure to Ensure Accurate Medication Administration and Self-Administration Assessments
Penalty
Summary
The facility failed to ensure accurate administration of medication for two residents, resulting in deficiencies related to medication management and adherence to facility policy. For one resident with chronic kidney disease, asthma, hypertension, anxiety, and depression, surveyors observed that medication was left at the bedside in a container of pudding, with 14 pills visible and others disintegrating, hours after the morning medication pass. Staff did not return to check if the medication was taken, yet documented the medications as administered. The resident reported not taking the medications and indicated that staff had not returned to verify consumption. Additionally, expired over-the-counter medications were found at the bedside, and there was no self-administration assessment or care plan authorizing self-administration or bedside storage of medications for this resident, despite a physician's order requiring staff to recheck within an hour. Another resident, with diagnoses including debility, cardiorespiratory conditions, neurogenic bladder, end stage renal disease, hypertension, diabetes, and anxiety disorder, was observed to have medication left at the bedside by a medication technician. Although this resident had a physician's order for unsupervised self-administration and a care plan intervention to assess self-administration ability on admission, quarterly, and with changes in condition, the most recent self-administration assessment was not current, with the last one completed several months prior. Facility policy required quarterly assessments and documentation for residents self-administering medications, which was not followed in this case. Interviews with staff, including the DON and NHA, confirmed that facility policy mandates staff to return and check if residents have taken medications left at the bedside and to complete and document self-administration assessments as required. The failure to observe medication consumption, accurately document administration, and maintain up-to-date self-administration assessments led to the identified deficiencies for both residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in outside storage receptacles, potentially affecting all 32 residents. On the morning of November 18, 2024, a surveyor and the Nursing Home Administrator (NHA) observed two outside garbage receptacles with open lids. The NHA acknowledged that the receptacle lids were routinely left open during the AM shift due to their height, which made it difficult for staff to close them. The maintenance staff ensured the lids were closed in the evening. A neighbor had previously complained about garbage being left outside and had confronted the staff. An anonymous person confirmed that the receptacle lids were often left open, causing a foul smell, especially during the summer, and mentioned that calls to the facility about this issue went unanswered.
Unqualified Dietary Manager and Lack of Full-Time Dietitian
Penalty
Summary
The facility did not designate a person to serve as the food and nutrition services director who met the required qualifications. The Dietary Manager (DM-D) had completed a ServSafe course but had not completed an approved dietary manager or food service manager certification course, nor did DM-D have an associate's or higher-level degree in food service management or hospitality. DM-D had no prior experience or training in food service management and was unaware of several regulatory requirements, including cleaning and disinfecting the ice machine filter, maintaining a testing log for sanitizing buckets, and dating bread. The facility did not have a full-time dietitian onsite, although a dietitian visited weekly and was available via email. This deficiency had the potential to affect all 31 residents residing in the facility.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a safe and sanitary manner, potentially affecting all 31 residents. During an initial kitchen tour, the surveyor observed an ice machine with a gray plastic filter containing dark, slimy areas. The Dietary Manager (DM) confirmed the presence of the black slimy substance and admitted to not cleaning the filter. Additionally, two microwaves were found with dried food debris inside, which the Dietary Aide (DA) acknowledged should have been cleaned. The freezer in the solarium lacked a thermometer and a temperature log, which the DM confirmed should have been maintained by the activity staff. Multiple food items were found without open or use-by dates, including loaves of bread, a gallon of milk, a package of devil's food cake mix, and bowls of fruit on the snack cart. The DA confirmed that these items should have been dated upon delivery or opening. Furthermore, the facility did not maintain logs for testing the parts per million (PPM) of the sanitizer buckets. The DM admitted to recently receiving test strips but was unaware that staff should maintain a testing log. The surveyor's findings indicate that the facility failed to adhere to the Wisconsin Food Code, which mandates specific cleaning frequencies for equipment, proper dating of food items, and maintenance of temperature logs and sanitizer testing records. These deficiencies were confirmed through observations, staff interviews, and record reviews, highlighting lapses in the facility's food safety and sanitation practices.
Failure to Meet PASRR Requirements for Multiple Residents
Penalty
Summary
The facility did not ensure that Pre-Admission Screen and Resident Review (PASRR) requirements were met for four residents. Resident 24 was admitted with a diagnosis of spastic diplegic cerebral palsy, and although a PASRR Level I Screen was completed, it did not indicate an intellectual disability/developmental disability (ID/DD). The facility did not obtain a county exemption or complete a Level II Screen for Resident 24. Similarly, Resident 26's PASRR Level I Screen was not completed timely, and a county exemption was not obtained. Resident 5's PASRR Level I Screen indicated a mental illness (MI) and the use of psychotropic medication, but the facility did not obtain a county exemption, and the Level II Screen was completed six days after admission. Resident 133's PASRR Level I Screen also indicated an MI and the use of psychotropic medication, but again, no county exemption was obtained, and the Level II Screen was completed six days after admission. Interviews with facility staff revealed that the social worker initially marked Resident 24 as having an ID/DD but was advised by a contracted agency to change the response, and no documentation of this conversation was kept. The social worker also admitted to not completing county exemptions for residents with MI or ID/DD prior to admission. The Nursing Home Administrator was unaware of this practice and was unsure of the process for county exemptions following recent changes in the PASRR system. This lack of adherence to PASRR requirements and proper documentation led to the deficiencies identified by the surveyors.
Failure to Follow POAHC Wishes for Resident Admissions
Penalty
Summary
The facility did not ensure the wishes of two residents were followed when they were admitted despite their Power of Attorney for Healthcare (POAHC) paperwork indicating they did not want to be admitted to a nursing home. Resident 23, who had severe cognitive impairment, was admitted for rehabilitation but remained in the facility for long-term care. The POAHC paperwork signed by Resident 23 in 2018 explicitly stated that the health care agent could not admit them to a nursing home for purposes other than recuperative or respite care. Despite this, Resident 23 was admitted to the facility on [DATE] and had no active discharge plan as of the latest assessment dated [DATE]. The social worker confirmed awareness of the POAHC restrictions but indicated that the resident needed to go through the court system to remain in the facility based on their wishes when the POAHC documents were created. Similarly, Resident 25, who also had severe cognitive impairment, was admitted to the facility despite their POAHC paperwork indicating they did not want to be admitted to a nursing home for long-term care. The POAHC paperwork signed by Resident 25 in 2005 stated that the health care agent did not have the authority to admit them to a nursing home for a long-term stay. Resident 25 was admitted to the facility on [DATE] and had no active discharge plan as of the latest assessment dated [DATE]. The social worker indicated that the family planned for Resident 25 to stay at the facility and discussed discharge with the POAHC, who decided against it. The social worker acknowledged that the resident should not have been admitted for long-term care without going through the court system, based on the POAHC documents.
Failure to Notify Physician and POAHC of Resident's Injury
Penalty
Summary
The facility failed to notify a physician and the Power of Attorney for Healthcare (POAHC) of a change in condition for a resident (R25) who had severe cognitive impairment and was receiving hospice services. On 2/26/24, staff observed a bump and bruise on R25's head, but there was no documentation in the medical record indicating that the physician or POAHC were notified. Additionally, there were no progress notes, skin assessments, pain assessments, or follow-up documentation after the injury was discovered. Interviews with staff and review of the facility's records revealed inconsistencies and lack of communication regarding the incident. The President of Clinical Services (VPCS-C) completed a Risk Management Report indicating that the physician and POAHC were notified, but this report was not part of the resident's medical record. Interviews with the POAHC and the physician confirmed that they were not notified by the facility about the injury. The facility's Nursing Home Administrator (NHA) acknowledged that the physician and POAHC should have been notified and that the notification should have been documented in the resident's medical record. The lack of proper documentation and communication led to the deficiency identified by the surveyor.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for two residents. One resident, admitted with a diagnosis of cerebral infarction, had a smoking care plan and was observed smoking, but their MDS assessment did not indicate tobacco use. The Minimum Data Set Coordinator (MDSC) acknowledged missing the smoking assessment. Another resident, admitted with obstructive sleep apnea, had a physician order for continuous positive airway pressure (CPAP) therapy, and a CPAP machine was observed in their room. However, their MDS assessment did not reflect the use of a CPAP machine. The MDSC confirmed the oversight in coding the CPAP usage.
Failure to Safely Store Smoking Materials for Resident
Penalty
Summary
The facility did not ensure that smoking materials were safely stored for one resident (R23). R23's care plan indicated that staff should store R23's smoking materials when not in use. However, on multiple occasions, the surveyor observed cigarettes and a lighter on R23's bedside table. R23 was admitted with a diagnosis of cerebral infarction (stroke) and had a severely impaired cognition score of 0 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Despite the care plan's intervention to store R23's smoking materials, these items were found in R23's room on several occasions between 3/25/24 and 3/26/24. Interviews with facility staff confirmed that R23 should not have smoking materials in the room. Certified Nursing Assistant (CNA)-K and Social Worker (SW)-L both indicated that R23's smoking materials should be stored securely, either at the nursing station or in SW-L's office. However, the surveyor observed that these materials were not properly stored, as they were found on R23's bedside table multiple times. This failure to follow the care plan and facility policy on smoking materials storage led to the deficiency noted in the report.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility did not ensure that a resident received the necessary care and services for respiratory therapy. Specifically, the resident was provided with CPAP therapy without a physician's order. Additionally, the resident's need for and use of CPAP therapy was not care planned, assessed, or monitored. The facility's CPAP Therapy policy outlines specific procedures for the use and maintenance of CPAP equipment, including the need for a physician's order and regular cleaning and maintenance of the equipment. However, these procedures were not followed in this case. The resident, who had diagnoses including obstructive sleep apnea, congestive heart failure, and type 2 diabetes mellitus, was observed with a CPAP machine on their nightstand. The machine's tubing was not labeled with a date to indicate when it was connected for use or last changed. Interviews with staff confirmed that the resident did not have an order for CPAP therapy or a cleaning schedule. The resident also indicated that the CPAP machine had not been cleaned since their admission. The Assistant Director of Nursing confirmed that the resident should have had an order for CPAP therapy, a cleaning schedule, and a care plan with interventions for CPAP use.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility did not ensure food preferences were honored for one resident (R4) of 14 sampled residents. R4's meal card specified no gravy and no mashed potatoes, yet on 3/26/24, R4 was served mashed potatoes with gravy for lunch. R4, who had intact cognition as indicated by a BIMS score of 15 out of 15, expressed that their food preferences were not consistently honored. R4 preferred regular scrambled eggs but was repeatedly served pureed eggs for breakfast, despite informing staff multiple times about this preference. On 3/26/24, R4's lunch included items that were against their stated preferences, leading R4 to refuse the meal due to the presence of gravy on the scalloped potatoes and mashed potatoes, which also partially covered the pureed peas. The Dietary Manager (DM-D) confirmed that R4's food preferences included no gravy and a choice between pureed or soft foods. DM-D acknowledged that R4's meal should have honored these preferences and admitted to being unaware of the errors. The dietary department's process involved printing menus every Thursday and allowing residents to make changes, but this process failed to accommodate R4's specific requests. The DM-D confirmed that the lunch meal served to R4 contained mashed potatoes and gravy, which should not have been included according to R4's preferences.
Incomplete Medical Record Documentation for Resident Injury
Penalty
Summary
The facility did not ensure that a medical record contained accurate and complete information for a resident identified as R25. On 2/26/24, staff discovered a bump and bruise on R25's head, but R25's medical record did not contain any information regarding the injury. The resident, who had Alzheimer's disease and severely impaired cognition, was under hospice care and had an activated Power of Attorney for Healthcare. A hospice note dated 2/26/24 mentioned the injury, but no further documentation was found in the medical record regarding notifications, follow-up, assessments, care plan updates, or an investigation into how the injury occurred. A Risk Management Report completed on 2/26/24 by the President of Clinical Services described the incident and indicated that the resident was seen leaning forward to reach for a dropped utensil, which caused the bruise. The report noted that the physician and Power of Attorney for Healthcare were notified, but this information was not included in the resident's medical record. Both the Nursing Home Administrator and the President of Clinical Services confirmed that Risk Management Reports are not part of the residents' medical records, and the Nursing Home Administrator verified that the medical record should have contained documentation regarding the injury and follow-up actions.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for one resident. During an observation of peri and Foley care for a resident, a CNA did not appropriately remove gloves and cleanse hands as per the facility's Hand Hygiene/Handwashing policy. The policy indicates that hand hygiene should be performed before and after direct contact with a patient, after contact with blood or body fluids, and after glove removal, among other instances. However, the CNA failed to perform hand hygiene after removing gloves and before donning new ones during the care process. The resident involved had a medical history including spina bifida, paraplegia, neuromuscular dysfunction of the bladder, MRSA, and CRE. The resident was dependent on staff for transfers, bed mobility, dressing, and personal hygiene. During the observed care, the CNA removed gloves and donned new ones without sanitizing hands, touched the resident and their blanket, and continued care near an open wound without proper hand hygiene. This failure to follow proper infection control procedures was verified by the CNA during an interview with the surveyor.
Failure to Retain Nurse Staffing Data
Penalty
Summary
The facility did not retain daily nurse staffing data for the required minimum 18 months. On 3/25/24, a surveyor reviewed the facility's nurse staffing posting and requested to review the previous three months of nurse staffing postings. On 3/26/24 at 10:30 AM, the surveyor interviewed the Nursing Home Administrator (NHA)-A, who indicated that the facility did not have the requested three months of nurse staffing postings. NHA-A stated that the night nurse did not save the nurse staffing postings as required. On 3/27/24 at 2:15 PM, a follow-up interview with NHA-A confirmed that the nurse staffing postings were not maintained as required.
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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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