Beloit Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beloit, Wisconsin.
- Location
- 1905 W Hart Rd, Beloit, Wisconsin 53511
- CMS Provider Number
- 525273
- Inspections on file
- 25
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Beloit Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with schizophrenia missed multiple doses of prescribed Seroquel over several days due to the medication not being available, and staff did not notify the physician or document required actions. Despite facility policy and available contingency supply, nursing staff failed to administer the medication, notify the provider, or document assessments and pharmacy contacts as required.
A resident with multiple chronic conditions and non-pressure wounds did not have wound care treatments completed or documented on several occasions, as shown by blank entries and missing progress notes in the TAR. After returning from a hospital stay, the resident also did not receive a full wound assessment, contrary to facility policy and staff expectations.
A resident did not receive pressure ulcer care as ordered, with multiple missed and undocumented wound treatments to the sacrum and bilateral ischial tuberosities. Nursing staff confirmed that blank entries on the TAR indicated treatments were not completed, and there were no progress notes explaining the omissions. This resulted in a failure to provide care consistent with professional standards and facility policy.
A resident was observed vaping inside the facility on two occasions, in violation of the facility's smoking policy. Despite these incidents, the care plan was not updated, no new smoking assessment was completed, and the resident retained access to vaping supplies. Facility leadership confirmed that required reassessment and care plan revisions were not performed.
A resident with schizophrenia was not given their prescribed Seroquel for several days, despite facility policy requiring staff to use contingency supplies, notify the pharmacy and physician, and document actions taken. Nursing notes showed repeated missed doses, and interviews confirmed that required notifications and assessments were not documented or completed.
A resident with Type 2 Diabetes Mellitus did not receive their scheduled insulin dose, leading to acute hyperglycemia and hospitalization. The facility failed to administer the insulin as ordered and did not have blood glucose monitoring in place. Interviews with staff confirmed the medication was not signed out on the MAR, and the DON acknowledged the oversight, which could have potentially prevented the hospitalization.
The facility failed to follow its Antibiotic Stewardship Program, leading to inappropriate antibiotic prescriptions for three residents. One resident with a history of antibiotic resistance received antibiotics for asymptomatic bacteremia five times, resulting in actual harm. Another resident was treated for a UTI without meeting criteria, and a third resident received antibiotics for an acute kidney injury without justification. The facility did not adequately review urine culture reports or educate physicians on proper antibiotic use.
The facility inaccurately reported staffing data to CMS, triggering deficiencies for low weekend staffing over five fiscal quarters. Interviews revealed a lack of understanding among staff about the facility's staffing assessments and reporting processes. Despite managerial assistance on weekends, these hours were not included in the PBJ reports, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program, with outdated policies and inadequate contact tracing and testing during a COVID-19 outbreak. Contact tracing was not completed for some residents, and testing was delayed for others, potentially contributing to the virus's spread. Additionally, breaches in infection control techniques were observed during resident care, indicating a lack of proper training and adherence to protocols.
The facility failed to serve meals at times in accordance with residents' preferences, affecting all 58 residents. A resident reported receiving lunch and dinner significantly later than scheduled, while another expressed distress over consistently late meals. A third resident noted that late breakfast delivery impacted his ability to eat lunch. The Nutrition Services Director cited staffing challenges as the cause.
The facility failed to maintain a safe, clean, and homelike environment for residents, with issues such as unclean floors, broken furniture, and room disrepair. Staffing and communication problems contributed to these deficiencies, as cleaning was not performed due to a housekeeper's departure, and maintenance issues were not reported or addressed promptly. Residents were left with inadequate living conditions, impacting their comfort and safety.
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and grooming. A resident did not receive scheduled showers, another did not receive recommended oral care, and a third was inaccurately documented as independent in oral hygiene. Additionally, a resident's long and dirty fingernails indicated a lack of grooming assistance.
A facility failed to provide adequate nursing staff, resulting in long wait times for resident assistance and unmet care needs. Residents reported waiting over an hour for call lights to be answered, especially on weekends. Staff interviews revealed that CNAs were responsible for more residents than the facility's stated ratio, leading to incomplete care tasks. The DON acknowledged staffing challenges and the lack of call light audit documentation.
A resident in a LTC facility had a lidocaine patch left on overnight, contrary to the facility's medication administration policy. The LPN discovered the error during a medication session, noting the patch lacked a date or initials. The facility was out of the prescribed 5% patch, leading to a switch to a 4% patch without proper documentation of the overnight error. The DON recognized this as a medication error.
A facility was found to have a medication error rate of 10.71%, exceeding the acceptable 5% threshold. Errors involved incorrect dosing and administration for two residents. One resident received an incorrect dose of Sevelamer, while another was nearly given another resident's medication and had issues with a lidocaine patch application. These errors were observed by a surveyor during a medication pass task.
The facility failed to provide consistent wound care for residents with pressure injuries, as treatments were not completed as ordered for three residents. One resident with multiple stage 4 pressure ulcers frequently missed treatments due to leaving the facility, while another with hemiplegia and diabetes had several missed treatments documented. A third resident with paraplegia and lung cancer also experienced missed treatments. Staff interviews confirmed that a blank in the TAR indicated a missed treatment, contributing to the deficiency.
A facility failed to ensure a safe environment for three residents. One resident smoked without an assessment or care plan, another's electric wheelchair was improperly charged in their room, and a third used an electric scooter without a prior safety assessment. Staff were aware of these issues but did not adhere to facility policies.
A resident's grievances regarding Hoyer lift transfers and a staff interaction were not documented or resolved, violating the facility's grievance policy. The resident experienced pain during transfers due to an inadequate lift, and a rude comment from a CNA was not addressed. Despite staff awareness, no formal grievance process was followed.
A resident admitted with anoxic brain damage did not receive a baseline care plan review within 48 hours, as required by facility policy. Interviews with staff revealed that the initial care plan is typically discussed at a care conference held within 72 hours, rather than the mandated 48-hour period. The DON acknowledged the expectation for timely sharing of the care plan.
A facility failed to create a comprehensive person-centered care plan for a resident with hemiplegia and cognitive impairment. The resident expressed pain when staff mishandled her left arm, a preference not documented in her care plan. Despite the resident's regular requests, a CNA continued to handle the arm improperly, leading to discomfort. The DON acknowledged the need for the resident's preferences to be included in the care plan.
The facility failed to involve two residents in the care planning process and did not update a resident's care plan to reflect a change in code status. One resident did not have quarterly care plan meetings, while another's care plan was not updated to show a DNR status despite a signed form and hospice admission.
A resident's medical orders were delayed in transcription for two days, leading to a lapse in timely treatment. The orders included nutritional supplements, dressing changes, surgery, an antibiotic, and a lipid profile. Facility staff confirmed that orders should be transcribed on the day received, but this did not occur, although no adverse effects were reported.
The facility failed to properly label and manage food items in the medication room refrigerator, resulting in expired thickened liquids and chocolate milk being stored. Despite policies requiring labeling and timely disposal, staff interviews revealed a lack of adherence to these standards, leading to expired items not being removed.
The facility failed to properly label and store medications, as observed during a survey. Expired liquid Tylenol was found in the medication room, and an open insulin vial lacked an open date. On a medication cart, artificial tears were improperly labeled, missing full resident names and open dates. Staff confirmed these medications should have been labeled according to facility guidelines.
The facility did not ensure food was served at palatable temperatures, as reported by two residents and confirmed by a test tray. A resident with diabetes and heart disease reported cold food, while another with mild cognitive impairment noted lukewarm meals. A test tray showed food temperatures below standard, with mushy noodles. The Nutrition Services Director cited issues with staff leaving warming boxes open.
Failure to Notify Physician and Administer Antipsychotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify and consult with a physician after a resident missed multiple doses of a prescribed antipsychotic medication, Seroquel, over several days. The resident, who had a diagnosis of schizophrenia, had physician orders for Seroquel to be administered three times daily. Nursing progress notes repeatedly documented that the medication was not available in the medication cart and was either on order or awaiting delivery for an extended period, spanning from 12/21/24 through 12/30/24. Despite these ongoing missed doses, there was no documentation that the resident's physician was notified of the missed medication, as required by facility policy. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed that facility policy and staff expectations were to check the contingency medication supply, contact the pharmacy for stat delivery, and notify the physician when a medication was unavailable. Staff also indicated that these actions, as well as any assessments related to missed medications, should be documented in the resident's medical record. However, the surveyor found no evidence in the record that the physician was notified, the pharmacy was contacted for stat delivery, or that any assessments were completed regarding the missed Seroquel doses for the resident during the period in question. Additionally, the facility's contingency medication supply was found to contain Seroquel 25 mg, which could have been used to prevent missed doses. Despite this, the medication was not administered, and the required notifications and documentation were not completed. The facility's own policies on notification of changes and medication error reporting were not followed, resulting in a failure to ensure timely physician consultation and appropriate documentation when the resident did not receive their prescribed medication.
Failure to Complete and Document Wound Care and Assessment
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including metabolic encephalopathy, type 2 diabetes mellitus, cellulitis, open wounds to both lower extremities and right foot, peripheral vascular disease, and congestive heart failure, did not receive wound care in accordance with physician orders and facility policy. The Treatment Administration Record (TAR) for this resident showed blank entries on specific dates, indicating that wound care treatments were not completed or documented. On one occasion, a code indicating 'other/see nurse's notes' was used, but no corresponding nurse's note was found to explain the omission. Multiple staff interviews confirmed that a blank TAR entry means the treatment was not completed, and a code requires a progress note, which was missing. Additionally, after the resident returned from a hospital stay, a full assessment of the resident's non-pressure wounds was not completed as required. The admission/readmission evaluation documented the presence of multiple open areas and significant edema, but staff, including the Assistant Director of Nursing and Director of Nursing, acknowledged that a comprehensive wound assessment should have been performed upon readmission. These actions and omissions were not in accordance with professional standards of practice, the resident's care plan, or facility policy.
Failure to Provide and Document Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident received pressure ulcer care in accordance with professional standards and physician orders, as evidenced by multiple missed and undocumented wound treatments. The facility's policy requires that wound care be provided as ordered, with all treatments documented on the Treatment Administration Record (TAR) or in the electronic health record. For the resident in question, the TAR showed numerous blank entries for both sacral and bilateral ischial tuberosity wounds, indicating that wound care was not completed or not documented as completed on several occasions over a two-month period. Interviews with nursing staff, including RNs, LPNs, the Assistant Director of Nursing/Wound Nurse, and the Director of Nursing, confirmed that a blank TAR entry means the treatment was not completed, and that a specific code (the number 4) would indicate a progress note explaining why a treatment was missed. In this case, there were multiple dates with blank TAR entries and no corresponding progress notes, confirming that wound care was not provided or not documented as required. The resident had orders for specific wound care regimens, including cleansing with Vashe wound cleanser, application of skin prep, use of hydrofera blue classic and other dressings, and securing with various tapes and pads. Despite these orders, the TAR indicated that treatments to the sacrum were not documented as completed 26 times, and treatments to the bilateral ischial tuberosities were not documented as completed 11 times. This lack of documentation and completion of wound care represents a failure to provide care consistent with professional standards and the facility's own policies.
Failure to Update Care Plan and Supervision After Resident Vaping Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident who was observed vaping inside the facility, contrary to the established smoking policy. The resident's care plan allowed for unsupervised smoking, and their smoking supplies were kept on their person. Despite two documented incidents where the resident was found vaping inside the facility, including one instance where the resident was educated about the policy but did not comply, no new smoking assessment was completed, and the care plan was not updated to address the non-compliance. Facility policy required that electronic cigarettes be used only in designated smoking areas and that a safe smoking assessment be completed for all residents using e-cigarettes. The policy also stated that the care plan should be revised to include additional safety measures if a resident did not abide by the smoking policy. Interviews with the ADON and DON confirmed that appropriate reassessment and care plan updates were not performed following the incidents, and the resident continued to have access to their vaping supplies.
Failure to Provide Prescribed Antipsychotic Medication and Follow Medication Error Protocols
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of schizophrenia was not provided with their prescribed Seroquel (an antipsychotic medication) for several days. The physician's orders specified that the resident was to receive Seroquel 25 mg at three different times daily. However, nursing progress notes repeatedly documented that the medication was not available in the medication cart and was on order or awaiting delivery over a period spanning multiple days. There was no documentation indicating that the medication was administered during this time. Interviews with nursing staff, including LPNs, RNs, the ADON, and the DON, revealed that facility policy requires staff to check the contingency medication supply, contact the pharmacy for stat delivery, and notify the physician when a medication is unavailable. Staff also indicated that daily assessments should be completed and documented, and that missed medications constitute a medication error requiring risk management review. Despite these protocols, there was no evidence in the medical record that the pharmacy or physician was notified, or that assessments were completed for the missed doses of Seroquel. Additionally, the surveyor confirmed that the facility's contingency supply did contain Seroquel 25 mg, which could have been used to administer the medication. The lack of documentation and failure to follow established procedures resulted in the resident missing multiple doses of a critical medication, with no evidence of appropriate follow-up or communication as required by facility policy.
Failure to Administer Insulin Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the case of a resident with Type 2 Diabetes Mellitus who did not receive their scheduled insulin dose. The resident was admitted to the facility with a history of hyperglycemia and had a physician's order for insulin glargine to be administered once daily in the morning. However, on the morning of 7/24/24, the insulin was not administered, and there were no physician orders for blood glucose monitoring in place. This oversight led to the resident experiencing acute hyperglycemia, resulting in hospitalization and treatment with an insulin drip. Interviews with facility staff, including LPNs and the DON, revealed that the medication was not signed out on the MAR, indicating it was not administered. Staff acknowledged that blood glucose monitoring should have been ordered and conducted for a new admission with diabetes. The DON confirmed that the insulin was not given and that the lack of administration could have potentially prevented the hospitalization. The NP also indicated that regular blood glucose monitoring and the administration of the insulin could have prevented the need for hospitalization.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for three residents. Resident R16, who has a history of antibiotic resistance, was prescribed antibiotics for asymptomatic bacteremia on five occasions between March and July 2024, despite not meeting the criteria for treatment. The facility did not adequately review R16's urine culture and sensitivity reports, leading to the administration of antibiotics to which R16 had developed resistance. This oversight resulted in actual harm to R16, as indicated by the severity level 3 citation. Resident R34 was prescribed antibiotics twice in July 2024 for a urinary tract infection (UTI) without meeting the necessary criteria. The urine culture and sensitivity report for R34 indicated mixed flora, suggesting a contaminated sample, yet the facility proceeded with antibiotic treatment without obtaining a recollection of urine as recommended. This action was cited at severity level 2, indicating the potential for more than minimal harm. Resident R612 was prescribed antibiotics for an acute kidney injury, despite not meeting the criteria for such treatment. The urine culture and sensitivity report showed mixed flora, and the physician later discontinued the antibiotic order after realizing the resident did not have a UTI. This incident was also cited at severity level 2. The Director of Nursing acknowledged the facility's failure to follow the antibiotic stewardship protocol and the lack of education provided to prescribing physicians regarding the treatment of asymptomatic bacteriuria.
Inaccurate Staffing Data Reporting to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. This deficiency was identified over five fiscal year quarters, from April 2023 to June 2024, where the facility's weekend staffing data was consistently reported as excessively low. The facility's policy manual requires the submission of complete and accurate staffing information, including agency and contract staff, based on payroll and other verifiable data. However, the PBJ Staffing Data Reports for these quarters indicated that the submitted weekend staffing data was insufficient, triggering a deficiency for excessively low weekend staffing. Interviews with facility staff revealed a lack of understanding and communication regarding staffing assessments and reporting. Scheduler E, responsible for staffing according to census, was unaware of the facility assessment and did not understand why the facility was triggering for low staffing. The MDS Coordinator indicated that the facility assessment hours were historical and reviewed by corporate, while the Director of Nursing acknowledged that June was particularly challenging for weekend staffing. Despite having department heads assist on weekends, these hours were not reflected in the PBJ staffing numbers, contributing to the inaccurate reporting.
Inadequate Infection Control and COVID-19 Management
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by outdated policies and inadequate contact tracing and testing during a COVID-19 outbreak. The facility's infection prevention and control policies had not been reviewed annually, as required. During a COVID-19 outbreak in March 2024, the facility did not complete contact tracing for the first resident who tested positive, R613, and another resident, R614, who was exposed during a tornado drill. Additionally, the facility did not conduct timely COVID-19 testing for several residents who were exposed to the virus, including R8, R12, R13, R14, R26, R28, R41, R43, R47, R618, and R619. The facility's failure to adhere to its own policies and procedures for infection control was further demonstrated by the improper handling of a COVID-19 outbreak. The outbreak documentation revealed that contact tracing was not completed for R616, who was noted to have been in the main dining room for meals, contrary to the facility's assumption that she stayed in her room. Testing for exposed residents was not conducted according to the facility's policy, resulting in delayed testing for several residents, which could have contributed to the spread of the virus within the facility. Additionally, breaches in infection control techniques were observed during the care of R35. A CNA was seen placing clean washcloths on the edge of a potentially contaminated sink before using them for resident care. The CNA also used a gloved hand to remove zinc oxide from a container and applied it to different areas of the resident's body without changing gloves, which could lead to cross-contamination. These actions indicate a lack of proper training and adherence to infection control protocols among staff.
Late Meal Service in LTC Facility
Penalty
Summary
The facility failed to ensure that meals and snacks were served at times in accordance with residents' needs, preferences, and requests. This deficiency was observed to potentially affect all 58 residents in the facility. Specific residents, including R8, R41, and R35, expressed concerns about meals being served over an hour after the scheduled times. Surveyors observed meals being served 1 to 1.5 hours late, with breakfast scheduled for 7:45 AM, lunch for 11:45 AM, and dinner for 4:45 PM. The facility's policy on meal frequency was not adhered to, as evidenced by the late meal service. Resident R8, who is cognitively intact, reported receiving lunch after 1:00 PM and dinner after 6:00 PM, contrary to her preference for meals at specific times. R41, with mild cognitive impairment, also reported that meals were consistently late, causing distress. R35, who has mild cognitive impairment and Parkinson's, noted that late breakfast delivery affected his ability to eat lunch due to the meals being too close together. The Nutrition Services Director acknowledged the issue, attributing it to staffing challenges, including new staff turnover and a cook still learning the routine.
Deficiencies in Cleanliness and Maintenance in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed by surveyors. In the case of two residents, their rooms were found to have unclean floors with visible dirt, which was confirmed by a housekeeper who admitted that the floors were not cleaned due to a miscommunication and staffing issues. The Nursing Home Administrator acknowledged that the usual housekeeper had quit, leading to a lapse in cleaning services. Another resident expressed concerns about not being able to use her closet due to a broken dresser, forcing her to keep her clothes and personal items in boxes. Despite reporting these issues to the staff, the Maintenance Director was unaware of the problem until the surveyor's inquiry. The Social Worker also acknowledged the need for residents to have proper storage for their belongings, indicating a lack of communication and follow-up on maintenance requests. Additionally, a resident's room was observed to be in disrepair, with peeling paint, loose trim, and a stained ceiling tile. The Maintenance Director was aware of these issues but had not yet addressed them, citing them as a priority. The Nursing Home Administrator admitted that the room did not provide a homelike environment, and plans for future renovations were mentioned, but the current state of the room remained inadequate for the resident's comfort and safety.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for residents who are unable to carry out activities of daily living (ADLs), resulting in deficiencies in nutrition, grooming, personal, and oral hygiene for four residents. Resident 48 did not receive her scheduled showers twice a week, as documented on multiple occasions. Despite her cognitive intactness, she expressed dissatisfaction with the infrequency of her showers, which were supposed to occur on Tuesdays and Thursdays. The Director of Nursing (DON) acknowledged that the resident should receive showers as scheduled and additional ones if needed. Resident 38, who has severe cognitive impairment due to parkinsonism and unspecified dementia, did not receive the recommended oral hygiene care. The resident's care plan required assistance with brushing and flossing twice daily, as per the dentist's recommendations. However, documentation showed that oral hygiene was only provided once a day on several dates. The DON confirmed that the care plan did not include the necessary flossing assistance, and a CNA reported a lack of flossing supplies in the facility. Resident 15, with severe cognitive impairment and a self-care deficit, did not receive daily oral care as required. The Point of Care (POC) history inaccurately documented the resident as independent or not applicable for oral care on numerous occasions. Interviews with the resident's Power of Attorney and CNAs revealed that the resident was fully dependent on staff for oral hygiene, and there was confusion about the documentation process. Additionally, Resident 16 had visibly long and dirty fingernails, indicating a lack of assistance with grooming. Staff acknowledged the oversight, citing being behind on tasks as a reason for neglecting nail care.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged wait times for assistance and unmet care needs. Multiple residents reported waiting over an hour for call lights to be answered, particularly during weekends when staffing levels were lower. This lack of timely response led to frustration and feelings of neglect among residents, with some resorting to extreme measures such as calling the police for help. The facility's policy on call light response was not adhered to, as evidenced by residents' accounts of staff turning off call lights without providing immediate assistance. Interviews with staff members revealed that the shortage of nursing staff impacted their ability to complete essential tasks, such as assisting residents with walking, toileting, and performing restorative exercises. Certified Nursing Assistants (CNAs) reported being responsible for caring for 12 to 13 residents each shift, exceeding the facility's stated average nurse aide-to-resident ratio of 1:10. This staffing inadequacy resulted in incomplete care, with tasks like showering, teeth brushing, and range of motion exercises often left undone, compromising the residents' quality of life. The Director of Nursing (DON) acknowledged the staffing challenges and the lack of documentation for call light audits. Despite management's efforts to assist on the floor, the facility's assessment tool for determining appropriate staffing levels was not effectively implemented. The discrepancy between the expected and actual call light response times further highlighted the staffing deficiencies, as residents continued to experience delays in receiving necessary care and assistance.
Medication Administration Error with Lidocaine Patch
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, identified as R32, by not ensuring the proper administration and removal of a lidocaine patch. On September 10, 2024, it was observed that R32 had a lidocaine patch still on her arm that should have been removed the previous night. The facility's policy on medication administration requires medications to be administered as prescribed and removed according to schedule. However, during a medication administration session, an LPN discovered that the patch on R32's arm was not dated or initialed, indicating a lapse in following the facility's procedures. Further investigation revealed that the facility was out of stock of the prescribed 5% lidocaine patch, and a switch to a 4% patch was ordered by a Nurse Practitioner. However, there was no documentation that the Nurse Practitioner was informed about the patch being left on overnight. The Director of Nursing acknowledged the incident as a medication error, noting that the nurse should have contacted the doctor regarding the error to determine the appropriate course of action.
Medication Errors Exceeding Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 10.71%, exceeding the acceptable threshold of 5%. This was determined during a medication pass task involving four supplemental residents, where three errors were identified out of 28 opportunities. Two residents, R31 and R32, were directly affected by these errors. The errors were observed by a surveyor and involved incorrect dosing and medication administration. For resident R31, the error involved the administration of Sevelamer, a phosphate binder used to prevent low levels of calcium. The resident's medication administration record (MAR) indicated a prescription of two 800 mg tablets to be taken three times a day. However, RN H only prepared and dispensed one tablet. Upon being questioned by the surveyor, RN H acknowledged the mistake and corrected it by providing the second tablet before administering the medication to R31. Resident R32 experienced two medication errors. LPN I initially prepared and almost administered a medication intended for another resident, R463, before being corrected by the surveyor. Additionally, R32's prescribed 5% lidocaine patch was not applied as it was unavailable, and a 4% patch was used instead without proper documentation or notification to the nurse practitioner. The surveyor also noted that R32 had a lidocaine patch on her arm without a date or initials, indicating it had not been removed the previous night as required.
Inconsistent Wound Care for Residents with Pressure Injuries
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for three residents, who did not have their wound treatments completed as ordered. The facility's policy required wound treatments to be provided according to physician orders and documented in the Treatment Administration Record (TAR) or electronic health record. However, the survey revealed that treatments were not consistently administered or documented for these residents. One resident, with multiple stage 4 pressure ulcers and a history of paraplegia, chronic pain, schizophrenia, and bipolar disorder, frequently left the facility without receiving prescribed wound care. The resident's TAR showed numerous instances where treatments were not completed, and interviews with staff indicated that wound care was performed based on the resident's schedule rather than consistently at the same time each day. Another resident, with a history of hemiplegia, diabetes, and peripheral vascular disease, also had missed wound care treatments documented in the TAR. Despite physician orders, treatments were not completed on several occasions, and staff interviews confirmed that a blank in the TAR indicated a missed treatment. A third resident, admitted with paraplegia, diabetes, lung cancer, and morbid obesity, also experienced missed wound care treatments. The TAR indicated that treatments were not documented as completed on multiple occasions. Interviews with the Director of Nursing confirmed that a blank in the TAR meant the treatment was not done, and wound care was expected to be completed as ordered. These failures to provide consistent wound care as per physician orders contributed to the deficiency identified by the surveyors.
Deficiencies in Resident Safety and Policy Adherence
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. One resident, who was admitted with conditions including critical illness myopathy and acute respiratory failure, was found to be smoking without a proper assessment or care plan in place. Despite being cognitively intact, the resident was not listed as a smoker in the facility's records, and staff were aware of her smoking habits but did not complete the necessary evaluations or care plans. Another resident's electric wheelchair was observed charging in his room, contrary to the facility's policy that requires such devices to be charged in designated areas. Staff, including a CNA, ADON/IP, and DON, were unaware of the correct charging location, indicating a lack of communication and adherence to the facility's policy on power mobility devices. A third resident, who was cognitively intact and had diagnoses including parkinsonism and respiratory failure, used an electric scooter in the community without a prior safety assessment. The assessment was only completed after the resident had already used the scooter, which was against the facility's policy that requires an evaluation before the use of electric devices to ensure safety.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and resolve grievances for a resident, R23, who reported issues with Hoyer lift transfers and an interaction with a staff member. R23's care plan indicated the need for a Hoyer lift with a specific sling for toileting needs. However, the facility used a different Hoyer lift that was too short, causing R23's buttock to rub against the bed during transfers, resulting in pain. Despite staff, including CNAs and the DON, being aware of the issue, no grievance was documented or resolved. Additionally, R23 reported a grievance regarding a rude comment made by a CNA, which was documented in a letter intended for the DON. R23 was unsure if the letter was delivered, and the DON confirmed not receiving it. The facility's grievance policy requires grievances to be documented and resolved promptly, but this was not followed in R23's case. The facility's failure to document and resolve grievances violated its grievance policy, which mandates that grievances be recorded, investigated, and resolved within five days. The lack of documentation and resolution for R23's grievances highlights a deficiency in the facility's grievance handling process.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was reviewed with the resident or their representative and that a copy or summary of the care plan was provided within 48 hours of admission. This deficiency was identified for one resident, who was admitted with diagnoses including anoxic brain damage and a history of traumatic brain injury. The facility's policy requires that a baseline care plan be developed and shared within 48 hours of admission, but this was not done for the resident in question. Interviews with facility staff revealed inconsistencies in the process of initial care planning. The Minimum Data Set (MDS) coordinator indicated that the initial care plan is created through assessments in the electronic health record and discussed during the initial care conference, which is scheduled within 72 hours. However, the Licensed Practical Nurse (LPN) and Social Worker (SW) confirmed that the care plan is typically reviewed with the resident or representative at the care conference, not within the required 48-hour timeframe. The Director of Nursing (DON) was unable to confirm if the initial care plan was shared with the resident or representative within 48 hours, acknowledging the expectation that it should be.
Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R54, who was reviewed for person-centered care plans. R54, who has a history of hemiplegia affecting the left side, malignant neoplasm of the brain, anxiety, and depression, expressed that staff did not handle her left arm in a way that prevented pain. Despite R54's moderate cognitive impairment, she communicated her discomfort and specific needs regarding the handling of her left arm, which were not documented in her care plan or the CNA Kardex. During an observation, a CNA was seen assisting R54 from a recliner to a bed and grabbed R54's left mid-forearm, causing R54 to express pain. The CNA admitted to habitually grabbing the arm despite R54's regular requests not to. The Director of Nursing acknowledged that the CNA should have stopped when R54 expressed pain and dizziness and should have involved a nurse for assessment. The DON also confirmed that R54's specific preferences should have been included in her care plan, which was not done.
Deficiencies in Resident Care Planning and Documentation
Penalty
Summary
The facility failed to ensure that residents or their representatives had the right to participate in the care planning process, as evidenced by deficiencies found in the cases of two residents. One resident, who was cognitively intact, reported not having quarterly care plan meetings to discuss her care. The facility's records confirmed that there was a lack of documentation for a quarterly care plan meeting between her admission and the most recent quarterly care conference. This indicates a failure to involve the resident in the care planning process as required by the facility's policy. In another case, a resident's care plan was not updated to reflect a change in her code status to Do Not Resuscitate (DNR), despite the presence of a signed DNR form and her admission to hospice care. The facility's comprehensive care plan incorrectly listed her as Full Code. The staff responsible for updating care plans acknowledged the oversight, indicating that the care plan should have been updated when the DNR form was signed. This failure to update the care plan demonstrates a lack of adherence to the facility's policy of revising care plans to reflect significant changes in a resident's status.
Delayed Transcription of Medical Orders
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who had received medical orders that were not transcribed for two days. The resident had a healed wound on the right heel and received new orders from the physician, which included nutritional supplements, dressing changes, surgery for debridement, an antibiotic, and a lipid profile. These orders were received via fax but were not processed until two days later, resulting in a delay in treatment. Interviews with facility staff, including an LPN, the ADON/IP, and the DON, confirmed that the orders should have been transcribed on the day they were received. The delay was acknowledged by the facility, and it was noted that the resident's primary care provider and family were made aware of the situation. Despite the delay, the resident did not experience any adverse effects from the lapse in timely order processing.
Deficiency in Food Storage and Labeling in Medication Room Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in the medication room refrigerator was labeled and managed according to professional standards. During an inspection, surveyors observed that three cartons of thickened liquids and two half gallons of chocolate milk were opened and expired. The facility's policy on 'Food Safety Requirements' mandates that all food items be inspected for safe transport and quality upon delivery, and that refrigerated items be labeled, dated, and monitored to ensure they are used by their use-by date or frozen. However, the surveyor found that the medication room refrigerator contained items that were not properly labeled with open dates, and some items were past their recommended consumption period. Interviews with facility staff, including an LPN and the DON, revealed a lack of clarity and adherence to the policy. The LPN indicated that supplements and food items should be discarded if expired, but was unable to identify the owner of the chocolate milk. The DON confirmed that items in the medication refrigerator should have open dates and be discarded if expired, and mentioned that the night shift is responsible for cleaning out the refrigerator. Despite these procedures, the expired items were not removed, indicating a lapse in the facility's food safety practices.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed during a survey. In the medication room, five bottles of liquid Tylenol were found with expiration dates of July 2024, indicating they were expired and should not have been stored there. Additionally, an open vial of Lantus insulin for a resident was found in the medication room refrigerator without an open date, making it unclear how long it had been in use. The facility's policy requires medications to be labeled with an open date to ensure they are used within their effective period. On a medication cart, three bottles of artificial tears were found improperly labeled, with one bottle missing both the first and last name of the resident and an open date, while the other two bottles only had first names and no open dates. This lack of proper labeling could lead to confusion about which resident the medications belonged to, especially if residents shared the same first name. Interviews with nursing staff confirmed that the medications should have been labeled with full resident names and open dates to ensure proper administration and compliance with the facility's medication administration guidelines.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that all residents received food at a palatable temperature, as evidenced by observations, interviews, and record reviews. Resident R467, who has diagnoses including Type 2 Diabetes Mellitus, Essential Hypertension, and atherosclerotic heart disease, reported to the surveyor that the food served was cold. Similarly, Resident R41, who has a mild cognitive impairment as indicated by a BIMS score of 12, expressed concerns during a resident council meeting that hot food was sometimes served lukewarm and had been sent back to the kitchen for being cold. Additionally, a test tray was observed by the surveyor, with the meat and gravy measuring 111°F, noodles at 109°F, and mixed vegetables at 115°F, all of which were below the proper serving temperatures. The noodles were noted to be mushy and not palatable. The Nutrition Services Director acknowledged the issue, attributing it to staff leaving the warming box open while placing trays, causing the heat to escape. The facility's policy requires food temperatures to be recorded daily to ensure they meet food code standards, which was not adhered to in this instance.
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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 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.
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.
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 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.
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.
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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