Bradley Estates Nursing And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 6735 W Bradley Rd, Milwaukee, Wisconsin 53223
- CMS Provider Number
- 525325
- Inspections on file
- 42
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Bradley Estates Nursing And Rehab Llc during CMS and state inspections, most recent first.
Surveyors found that multiple residents lived in rooms with significant uncleanliness and disrepair, including soiled items, dust, stains, and broken fixtures. Some residents reported that staff did not clean under beds or repair damaged areas. Facility records did not show evidence of required deep cleaning, and maintenance staff were unaware of needed repairs, despite facility policies requiring regular cleaning and upkeep.
The facility did not address or resolve grievances raised by residents during council meetings over several months. Multiple residents, including those who were cognitively intact and impaired, reported that their concerns about activities, food, and other issues were repeatedly discussed without follow-up or resolution. Staff responsible for handling grievances were not consistently involved in the meetings, and meeting records showed no evidence of timely feedback or action on the issues raised.
A resident with severe cognitive and physical impairments was physically abused by their cognitively impaired roommate, who was observed by a CNA hitting the resident in the chest. Both residents were unable to recall the incident, and neither sustained injuries. The event occurred despite facility policies requiring protection from abuse.
A resident was found hitting another resident, and while the immediate incident was addressed and documented, the facility failed to interview other staff or residents who might have witnessed the event or had relevant information, as required by policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple medical conditions reported missing money from their room on two occasions. Despite facility policy requiring reporting of such allegations, the incident was not reported to the State Agency because staff believed there was insufficient evidence and inconsistencies in the resident's statements. The resident's care plan noted a preference to keep money on their person and refusal to use a lockbox.
A resident with intact cognition and multiple medical conditions reported missing money on two occasions, but the facility did not conduct a thorough investigation due to inconsistent statements and lack of evidence. The DON confirmed that no formal inquiry was initiated, and the incident was not documented in the resident's progress notes.
Surveyors found that a resident's room had a crooked window shade held up by hangers, large areas of missing paint, and a shared bathroom with uncovered linen and garbage carts emitting a strong fecal odor. A resident's wheelchair was also observed to be dirty with dried food and missing cushion parts. Staff confirmed these conditions were unacceptable and acknowledged improper storage and maintenance.
A resident with severe cognitive impairment and a history of falls was transferred without non-slip footwear and without a scoop mattress, both of which were required by the care plan. Staff inconsistently applied transfer methods, with some using a gait belt and assist of two instead of the required mechanical sit-to-stand lift. There was confusion among staff regarding the resident's transfer status, and no therapy evaluation was found to support changes in transfer method.
The facility did not act on or document responses to repeated grievances raised in resident council meetings regarding delayed call light responses and staff phone use. Multiple cognitively intact residents reported ongoing issues with staff not answering call lights and being inattentive, despite filing grievances and discussing these concerns in meetings. The facility conducted call light audits but did not document or communicate the results, and residents felt their concerns remained unaddressed.
Two residents with diabetes received insulin injections from LPNs who did not hold the insulin pen needle in the skin for the required five seconds after injection, contrary to the manufacturer's instructions. Both LPNs confirmed this practice, and the facility's policy referenced safe medication administration and the availability of manufacturer instructions online.
Two residents received insulin from multi-dose pens that were not labeled with the date and time of first use, contrary to facility policy and manufacturer instructions. Two LPNs administered insulin without ensuring the pens were properly labeled, and staff interviews revealed inconsistent knowledge of expiration guidelines. This resulted in the inability to verify whether the insulin was within its safe usage period.
An LPN failed to perform hand hygiene after removing gloves and before using the medication cart computer, and also did not clean the rubber septum of a new insulin pen before administering insulin to a resident. These actions were not in accordance with facility policy and were confirmed by the Unit Manager as not meeting expectations for infection prevention and control.
The facility did not have a qualified individual serving as the food and nutrition services director, as the current Dietary Manager had not completed or enrolled in an approved certification program or held a related degree, and the recently hired Assistant Dietary Manager only held a state-level certification. This affected all residents in the facility.
Surveyors found that multiple residents did not receive their medications as prescribed, with controlled substances not properly documented, incorrect dosages given, and numerous late or missed doses. LPNs failed to follow the facility's medication administration policy, and the DON and pharmacist confirmed these lapses in both timing and documentation.
Surveyors found that medication carts were left unlocked and unattended, and medications were stored in unlabeled and uncovered cups rather than in their original pharmacy packaging. Staff confirmed that these actions were not in line with facility policy, and these lapses had the potential to affect multiple residents.
Surveyors observed that staff did not serve the menu-listed cut potatoes to residents in the dining room and provided only half the required portion of potatoes to residents eating in their rooms. Staff interviews and record reviews confirmed that the posted menu and required serving sizes were not followed during the lunch meal.
Surveyors observed improper food handling and sanitation practices, including a dietary aide failing to follow hand hygiene and hair restraint protocols while plating food, and ice scoops being stored directly in or on top of ice in coolers. The dietary manager confirmed these actions did not meet facility policy or state food code requirements.
A resident with moderate cognitive impairment and an activated POAHC underwent pharmacogenomic testing without the POAHC being notified or providing consent. The resident verbally consented to the testing, and the facility could not determine which physician requested it, despite the Medical Director's signature on the order. The POAHC only learned of the testing through insurance correspondence, and the facility confirmed that proper notification and consent procedures were not followed.
A resident with significant physical disabilities did not receive scheduled weekly showers or regular toileting assistance as outlined in their care plan. Documentation of ADL care was inconsistent, with only two showers recorded and many shifts lacking completed records for required tasks. Staff confirmed that missing documentation meant care was either not provided or not charted, resulting in a deficiency related to unmet ADL needs and incomplete records.
An LPN was observed preparing and administering medications to two residents without performing hand hygiene, contrary to facility policy. The LPN acknowledged the omission, and the DON confirmed that hand hygiene is expected before medication preparation and administration.
A resident accessed a loaded firearm from a CNA's purse, and another resident suffered a third-degree burn from a leaking oxygen tank in an LTC facility. Both incidents were classified as immediate jeopardy due to the potential for serious harm, highlighting significant safety lapses and inadequate supervision.
A resident accessed a loaded gun from a staff's purse and carried it onto a secured memory care unit without notifying the POA. Another resident experienced skin irritation from an oxygen tank placement, but the physician and responsible party were not informed.
A resident with malignant neoplasms and repeated falls was transferred to the ER by family without receiving a bed hold notice, as required by the facility's policy. Staff interviews revealed a lack of communication and awareness regarding the bed hold policy, and the medical record confirmed no notice was provided.
A resident was not permitted to return to the facility after a hospital visit, despite the facility's policy allowing for such returns if needs can be met. Miscommunications and lack of documentation led to the resident being discharged against medical advice, and the facility initially refused readmission. The situation was resolved after intervention from an Ombudsman.
A resident with a Foley catheter experienced inadequate care and monitoring, resulting in hospitalization for urinary retention, UTI, and acute kidney injury. The facility failed to document urine output and genitourinary changes, and staff interviews revealed a lack of adherence to catheter management guidelines.
The facility failed to implement its abuse prevention policies by not conducting thorough background checks for three staff members. A Dietary Aide with a history of misconduct was hired without proper investigation, and a CNA was employed without timely DOJ documentation. Additionally, discrepancies in documentation for another staff member were noted, highlighting lapses in the facility's adherence to its policies.
A resident was verbally abused by a dietary aide who called them a derogatory name and threatened physical harm. The aide, who had a history of caregiver misconduct, was employed without a thorough background check. The incident required staff intervention, and the facility's failure to screen the aide properly contributed to the deficiency.
A resident with a history of aggressive behavior and severely impaired cognition was observed without the required 1:1 supervision on multiple occasions. Despite staff education on supervision expectations, the resident was left unsupervised in their room and dining area, contrary to their care plan. The facility's failure to adhere to supervision protocols was confirmed by staff and the Nursing Home Administrator.
A resident was discharged from an LTC facility without proper planning or medication after returning from a hospital stay. Despite planning to move into an apartment, the resident was told to leave following an argument with staff. The resident refused to sign AMA paperwork, and the facility did not provide medications upon discharge. Interviews revealed that the resident could have stayed until the apartment was ready, but this was not communicated, leading to a deficiency in care.
A resident with severe cognitive impairment and multiple eye-related diagnoses did not receive replacement glasses after their original pair was lost in the facility. Despite grievances filed by the resident's family, the facility did not document corrective actions or follow-up. Interviews revealed that the Grievance Officer was aware of the issue but did not act, and the Nursing Home Administrator admitted that new glasses should have been obtained.
A CNA in a long-term care facility was observed improperly handling clean towels by carrying them against their scrub top while delivering them to residents' rooms, contrary to the facility's infection control policy. An LPN corrected the CNA, emphasizing the need for using a cart to prevent contamination. The CNA acknowledged the mistake and the need for further training.
Two residents with epilepsy in a facility experienced significant medication errors, with one resident missing multiple doses of Lacosamide and Keppra, leading to hospitalization, and another missing doses of Clobazam due to staff unawareness of its location. The facility's medication management policies were not adhered to, resulting in these deficiencies.
Two residents were not involved in the development and implementation of their person-centered care plans. One resident, despite being cognitively intact, had no documented care conferences since admission. Another resident, with severe cognitive impairment, had no care conferences documented after March, despite multiple care plan revisions. The facility's policy requires patient involvement in care management meetings, but these were not conducted as required, partly due to staffing changes.
A resident's representative was not notified of significant treatment changes, including a rescheduled colonoscopy, an ER transfer, and medication adjustments. The facility's policy requires immediate notification, but documentation was lacking. The resident expressed a desire for their representative to be involved in all decisions, and the Nursing Home Administrator acknowledged the oversight.
A resident with ALS and other medical conditions filed a grievance about uncomfortable sleeping arrangements, requesting a new mattress or recliner. The facility failed to provide a resolution, citing the absence of wounds as a reason for not providing an air mattress. The resident continued to sleep in a narrow wheelchair, which was uncomfortable and restrictive, and the grievance remained unresolved.
Two residents in a LTC facility experienced injuries of unknown origin that were not reported to the State Survey Agency as required. One resident had bruising and swelling to the right eye, with conflicting staff accounts and no documentation of an incident. Another resident had a hand fracture initially misdiagnosed as gout, and the facility failed to submit a Self Report before determining a probable cause. These incidents indicate a failure to adhere to reporting policies.
A resident with multiple health conditions was found with a bruised and swollen eye, but the facility failed to conduct a thorough investigation. Conflicting accounts from staff and lack of documentation led to an incomplete understanding of how the injury occurred. The facility did not obtain statements from all involved staff, and no documented investigation was submitted to the State Survey Agency.
The facility failed to update care plans for two residents, leading to deficiencies in addressing their care needs. One resident's fall intervention was not added to their care plan, while another resident's care plan and Kardex lacked specific interventions for behaviors and safety measures. Staff interviews confirmed the need for updates, which were not made, resulting in inadequate guidance for care.
A resident experienced severe weight loss over seven months due to the facility's failure to implement new interventions or notify the physician, despite policies requiring such actions. The resident's care plan was not effectively monitored or adjusted, and inconsistencies in meal assistance and dietary preferences were noted. The facility's inaction led to a deficiency in maintaining the resident's nutritional status.
A resident receiving Ativan as a PRN medication did not have a documented rationale or duration for use beyond 14 days, as required by facility policy. Despite regular administration, the facility failed to document a stop date or re-evaluate the necessity of the medication, leading to a deficiency in managing psychotropic medications.
A resident with ALS and high risk for pressure injuries was forced to sleep in her wheelchair due to an uncomfortable bed. Despite filing a grievance and requesting a new mattress or recliner, the facility did not provide an alternative, citing that the resident did not qualify for an air mattress as she had no wounds. The facility considered the grievance resolved, but the resident continued to express discomfort and lack of a suitable sleeping arrangement.
A resident with a history of anxiety and depression, admitted after a stroke, was not reassessed for the need of a power of attorney for healthcare, nor were alternatives to the antidepressant Sertraline explored, despite the resident's refusal to take it. The facility failed to develop a care plan for the resident's agitation and desire to leave, leading to the resident attempting to exit the facility using bed sheets, resulting in serious injuries. The lack of comprehensive discharge planning and interdisciplinary care contributed to the resident's increased anxiety and isolation, culminating in immediate jeopardy.
A resident with a history of pressure ulcers and paraplegia developed a Deep Tissue Injury (DTI) due to the facility's failure to conduct required weekly skin checks and update the care plan with necessary interventions. Despite the resident's high risk for pressure injuries, the facility did not document assessments or treatments for the new DTI until months later, and there were inconsistencies in records regarding the resident's use of pressure-relieving boots.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in the Water Management Plan, infection surveillance, and Enhanced Barrier Precautions. The WMP lacked current standards and documentation, while infection surveillance was incomplete and did not address increased UTI rates. Additionally, the facility did not implement EBP for residents with catheters and wounds. Environmental issues in the laundry area, such as unclean washers and leaking grease tanks, further compromised infection control efforts.
The facility did not maintain mechanical and electrical equipment in safe operating condition, as evidenced by a leaking grease tank, significant lint accumulation in the dryer vent, and a leaking washing machine. The grease tank issue was known for weeks, with repairs delayed due to payment issues. Despite maintenance logs indicating recent checks, these deficiencies persisted, affecting all residents.
The facility did not provide mandatory QAPI program training to two CNAs, as confirmed by the NHA. This deficiency was identified through a review of training records, which showed no documentation of the required training. The absence of this training could potentially affect the care of 148 residents.
The facility did not ensure that two CNAs received annual training on the compliance and ethics program, as confirmed by the NHA. This oversight has the potential to impact the care of 148 residents.
The facility failed to complete required background checks for two staff members, potentially affecting resident care. A CNA hired in 2023 had delayed BID, DOJ, and IBIS form completion, while an Activity Aide hired in 2018 did not have updated forms within the required four-year period. HR acknowledged the oversight, and the NHA and DON confirmed the requirement but provided no explanation for the lapse.
The facility failed to provide required written transfer notices to residents and their representatives during hospital transfers. Ten residents with various medical conditions were transferred without receiving the necessary documentation. The Assistant Director of Nurses confirmed that the notices were not sent, and the facility could not provide the missing documentation upon request, indicating a systemic issue.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for eight residents, as evidenced by multiple observations of uncleanliness and disrepair in resident rooms and shared spaces. Surveyors observed used urinals, uncovered hampers with soiled clothing emitting strong odors, thick layers of dust on wall heaters and window shelves, sticky floors, candy wrappers, cobwebs, and broken sink drain plugs. Additionally, there were visible stains, splatters, and scrapes on walls and ceilings, missing tiles, and exposed pressed wood in closets. Residents confirmed that staff did not move beds to clean underneath or repair damaged walls, and maintenance staff were unaware of the areas needing repair. The residents affected included individuals with varying levels of cognitive impairment, as indicated by their BIMS scores, ranging from severely impaired to cognitively intact. The observations were confirmed by the Regional Manager of the contracted housekeeping service, who acknowledged staffing shortages and delays in cleaning due to call-offs and weather-related lateness. The facility was unable to provide evidence that deep cleaning had been performed in resident rooms for the month in question, as requested by surveyors. A review of facility policies revealed that daily cleaning procedures required high dusting and disinfection of high-touch surfaces, and the homelike environment policy emphasized providing a safe, clean, and comfortable setting. Despite these policies, the observed conditions did not meet the outlined standards, and the lack of documentation for deep cleaning further demonstrated the facility's failure to ensure a clean and homelike environment for its residents.
Failure to Resolve Resident Council Grievances in a Timely Manner
Penalty
Summary
The facility failed to resolve grievances raised during resident council meetings in a timely manner for three out of six monthly meetings, as evidenced by interviews, record reviews, and policy review. Three residents, including two who were cognitively intact and one who was severely cognitively impaired, confirmed that issues such as requests for more puzzles, shopping trips, fresh fruit and vegetables, snacks, and specific meal preferences were repeatedly brought up in council meetings without follow-up or resolution. Meeting minutes from multiple months showed that concerns were documented but not addressed, and there was no evidence of feedback or updates provided to the council members regarding the status of their grievances. Staff interviews revealed that the Concierge, responsible for addressing grievances, was not invited to several resident council meetings and only recently began attending after being invited by the council president. Residents and council attendees expressed frustration over the lack of follow-up, with complaints remaining unresolved from month to month. The facility's policy requires that council recommendations and issues be reviewed by the Administrator and that responses be presented at the next meeting or sooner, but this process was not followed as documented in the meeting minutes and confirmed by staff and resident interviews.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and limited physical mobility was not protected from physical abuse by their roommate, who also had cognitive and mobility impairments. The incident took place when a Certified Nursing Assistant (CNA) observed one resident hitting the other in the chest after hearing yelling from the room. The CNA immediately intervened and separated the residents. Both residents were unable to recall the incident or what led to it, and neither sustained injuries as a result of the altercation. The facility's records indicated that both residents had significant cognitive and physical limitations, with one resident having a history of Parkinson's disease, traumatic brain injury, and hemiplegia, and the other also experiencing hemiplegia and cognitive impairment. The facility's policy requires the protection of residents from abuse, neglect, and exploitation, but in this case, a resident was subjected to physical abuse by another resident in their shared living space.
Failure to Interview All Potential Witnesses in Resident-to-Resident Abuse Investigation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. According to the documentation, a certified nurse aide (CNA) heard a resident yelling and discovered another resident hitting him in the chest. The CNA immediately separated the two residents and assessed the victim for injuries, finding none. The incident was documented, and statements were obtained from the CNA and attempts were made to interview both residents involved. However, the investigation did not include interviews with other staff or residents who may have had knowledge of the incident or witnessed similar events. This omission was contrary to the facility's policy, which requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegation. The administrator confirmed that only the CNA was interviewed, as the incident was considered isolated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of missing money to the State Agency (SA) as required by its own policy and regulatory expectations. A resident, who had diagnoses including end stage renal disease, schizophrenia, and blindness in both eyes, reported that $650 was missing from a pill bottle kept in a dresser drawer after returning from dialysis. The resident had previously reported another incident of missing money. The facility's grievance form documented that the resident changed the reported amount of missing money several times and was unable to specify the denominations. The facility searched the resident's room but did not find the money and noted there was no evidence the resident had the reported amount. The resident was informed that the facility was not responsible for the missing money, and the risks and benefits of using a lockbox or sending valuables home were discussed. Despite the facility's policy requiring that all alleged violations, including misappropriation of resident property, be reported to the required agencies within 24 hours, the allegation was not reported to the SA. The Director of Nursing confirmed that the incident was not reported because of the lack of evidence that the resident had the money and the inconsistencies in the resident's statements. The resident's care plan indicated a preference to keep money on their person and a refusal to use a lockbox, with ongoing encouragement documented to use safer storage options. There was no documentation in the resident's progress notes regarding the complaint of missing money.
Failure to Investigate Allegation of Missing Resident Money
Penalty
Summary
The facility failed to thoroughly investigate an allegation of missing money for one resident. The resident reported that $650 was missing from a pill bottle kept in a dresser drawer after returning from dialysis. The facility's policy requires that all alleged violations, including misappropriation of resident property, be reported and investigated. However, the grievance form indicated that the facility did not find evidence that the resident had the money and noted inconsistencies in the reported amount and lack of knowledge about the denominations. The resident was informed that the facility was not responsible for the missing money, and the risks and benefits of securing valuables were discussed. The resident's care plan reflected a preference to keep money on their person and a refusal to use a lockbox, with interventions to encourage secure storage of valuables. Interviews and record reviews revealed that the resident had reported missing money on two occasions while residing in different units. The resident had intact cognition, as indicated by a BIMS score of 13 out of 15, and diagnoses including end stage renal disease, schizophrenia, and blindness in both eyes. The Director of Nursing confirmed that no investigation was conducted due to the lack of evidence that the resident possessed the money and the resident's changing statements regarding the amount. Progress notes did not document the resident's complaint of missing money, and the facility did not initiate a formal investigation into the allegation.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to provide a safe, clean, comfortable, and homelike environment for several residents. In one room, a window shade was found crooked and held up with plastic hangers, leaving half the window exposed, and the wall opposite the beds had large patches of missing paint, including one area approximately 8 feet long by 6 inches. The shared bathroom for four residents contained an uncovered linen cart filled to the top, another linen cart, and a large garbage can, all contributing to a very strong smell of feces. Additionally, a resident's wheelchair was found to have dried, crusty food particles and other unknown brown, crusty matter on various parts, with the left armrest missing parts of its cushion and beginning to expose the metal underneath. Staff interviews confirmed that the cleanliness of the wheelchair was not acceptable and that arrangements would be made to clean and sanitize it. The LPN stated that the linen and garbage bins were kept in the bathroom for easy access by CNAs and were used for all residents' linens and garbage. The acting administrator acknowledged that the window shade and wall required maintenance and that the storage of containers in the bathroom was inappropriate and could pose an infection issue. No additional information was provided regarding why proper storage and maintenance had not been completed.
Failure to Provide Adequate Supervision and Assistive Devices During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of falls received adequate supervision and assistive devices to prevent accidents. The resident, who is dependent on staff for transfers and has dementia, was observed being transferred from a wheelchair to bed without wearing non-slip footwear, contrary to facility policy and the resident's care plan. Additionally, the resident did not have a scoop mattress as documented in the care plan for fall prevention. During the transfer, staff used a mechanical sit-to-stand lift, but it was noted that the resident's transfer method had been inconsistently applied, with some staff using a gait belt and assist of two instead of the required mechanical lift. Interviews with staff revealed confusion and inconsistency regarding the resident's transfer status and required interventions. The CNA assigned to the resident reported using a gait belt and assist of two, while the LPN and ADON indicated the use of a mechanical sit-to-stand lift was required. The DON confirmed that changes to a resident's transfer status should involve therapy, but no therapy evaluation was found in the resident's record. The resident's Kardex and care plan both indicated the need for a sit-to-stand lift and a scoop mattress, but these interventions were not consistently implemented at the time of the survey.
Failure to Address Resident Council Grievances and Call Light Concerns
Penalty
Summary
The facility failed to act upon grievances raised during resident council meetings and did not demonstrate a response or provide rationale for their actions regarding these concerns. Resident council meeting minutes over several months documented repeated complaints about staff not passing snacks, delayed call light responses, staff using phones while providing care or sitting at the nurses' station, and staff rarely being present on the units. Despite these ongoing concerns being raised in multiple meetings, there was no documented evidence that the facility addressed or responded to the issues. Additionally, call light audits were conducted, but the results were not documented or shared. Multiple residents, all cognitively intact according to their MDS assessments, reported persistent problems with staff not responding to call lights in a timely manner and staff being distracted by personal phone use. Some residents filed formal grievances, which were logged, but interviews revealed that residents felt their concerns were not addressed and that the issues continued. The facility administrator stated that grievances from resident council were supposed to be resolved through the grievance process, but could not provide documentation of actions taken or outcomes related to the concerns raised.
Failure to Follow Manufacturer's Instructions for Insulin Pen Administration
Penalty
Summary
The facility failed to ensure that insulin was administered according to the manufacturer's instructions for two residents with diabetes mellitus who required insulin injections. Both residents had physician orders for insulin administration using a Humalog KwikPen. During medication administration observations, LPNs administered insulin to each resident but did not hold the pen needle in the skin for at least five seconds after injection, as required by the manufacturer's guidelines. Instead, the LPNs immediately withdrew the needle after injecting the insulin. Interviews with the LPNs confirmed that they did not follow the manufacturer's instructions regarding the required hold time after injection. The facility's policy stated that medications should be administered safely and as prescribed, and the insulin pen manufacturer's instructions were available online. The Unit Manager acknowledged that the instructions for insulin pen use could be found on the manufacturer's website.
Failure to Label Multi-Dose Insulin Pens with Open Date
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were labeled with the date and time when first opened for two residents during medication administration. During medication passes, two different LPNs administered insulin using Humalog KwikPens that were not labeled with the date they were first opened, as required by facility policy and manufacturer instructions. One LPN retrieved a new insulin pen, administered the medication, and returned it to the cart without labeling it. When questioned, the LPN stated the pen was the only one open but did not provide a method for other staff to know when it was first used. The other LPN, an agency nurse, administered insulin from an already open pen and was unable to state when it was first opened, incorrectly stating the pen was good for ninety days. Interviews with staff, including a unit manager, confirmed that the expectation is for insulin pens to be labeled with the open and discard dates, and that the pens are only good for twenty-eight days after opening. Facility policies reviewed also require that the date opened be recorded on multi-dose containers and that expiration dates be checked prior to administration. The lack of labeling on the insulin pens created a situation where staff could not verify whether the medication was still within its safe usage period, as required by both facility policy and manufacturer guidelines.
Failure to Perform Hand Hygiene and Proper Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to perform hand hygiene after removing gloves and before handling the medication cart computer mouse. The LPN discarded gloves in the trash and immediately began typing on the computer without sanitizing hands, contrary to the facility's Handwashing/Hand Hygiene policy, which requires hand hygiene after glove removal and as the final step after removing personal protective equipment. When questioned, the LPN indicated that hand hygiene would be performed after completing charting and also stated being an agency nurse. Additionally, during medication administration, the same LPN retrieved a new insulin pen for a resident and accessed the pen with a needle without first cleaning the pen's rubber septum. When asked about the requirement to clean the pen hub, the LPN stated that it was unnecessary for a new pen. The Unit Manager later confirmed that staff are expected to sanitize hands after glove removal and clean the insulin pen's hub before use, regardless of whether the pen is new. These actions were observed during medication administration for one resident and were inconsistent with facility policy, creating the potential for cross-contamination.
Lack of Qualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to designate a qualified individual to serve as the food and nutrition services director, as required by regulations. The person currently acting as Dietary Manager (DM) had worked at the facility for over a year and had completed ServSafe Managers training but was not enrolled in, nor had completed, an approved Dietary Manager or food service manager certification course, nor did they possess a related degree. The DM stated they were considering taking the Certified Dietary Manager (CDM) training but had not yet done so. An Assistant Dietary Manager was recently hired who held a State Food Safety Food Manager Certification, but this did not meet the federal requirements for the director position. This deficiency had the potential to affect all 147 residents in the facility.
Failure to Provide Timely and Accurate Medication Administration and Documentation
Penalty
Summary
Surveyors identified multiple failures in the facility's pharmaceutical services, specifically regarding the administration and documentation of medications for several residents. Controlled substances for three residents were not documented in the controlled substance log at the time of administration, and one resident received a lower dose of tramadol than prescribed. Additionally, several residents did not receive their scheduled medications within the required time frames, and some medications were not administered at all. These deficiencies were observed during direct medication passes, review of medication administration records, and interviews with nursing staff and the Director of Nursing. Residents affected by these deficiencies had a range of medical conditions, including degenerative nervous system disease, respiratory failure, anxiety, alcoholic cirrhosis, encephalopathy, end-stage renal disease, pulmonary hypertension, COPD, diabetes, schizophrenia, hypertension, major depression, influenza, spastic quadriplegia, and cerebral palsy. Cognitive status varied among the residents, with some having severe cognitive impairment and others being fully alert and oriented. The facility's own policy required medications to be administered safely, timely, and as prescribed, with a one-hour window for scheduled doses, but this policy was not consistently followed. The survey also revealed that one resident experienced a pattern of late or missed medication doses over a month-long period, with numerous instances where medications were not administered within the prescribed time frames or were omitted entirely. In some cases, medication doses were not spaced appropriately, failing to allow the intended interval between doses. Interviews with the DON and facility pharmacist confirmed these findings and acknowledged that the administration and documentation of medications did not meet the facility's standards or physician orders.
Improper Storage and Handling of Medications
Penalty
Summary
Surveyors observed that the facility failed to store drugs and biologicals in accordance with its own policy and accepted professional standards. On one occasion, an LPN left a medication cart unlocked and unattended in a hallway, with the drawers facing outward, while two residents in wheelchairs passed by. The LPN acknowledged that the cart should have been locked and stated that forgetting to lock it was an oversight. Another LPN was seen preparing and administering medication by removing a yellow pill from an unlabeled and uncovered medication cup in the top drawer of the medication cart, which contained several pills. This pill was then added to a resident's medication cup and administered. The LPN explained that the medication cart did not have the required medication, so they obtained a cup of the medication from another cart. Interviews with staff, including another LPN and the Director of Nursing, confirmed that medication carts should be locked when unattended and that all medications should be stored in their original packaging as dispensed by the pharmacy. The facility's policy specifies that only the issuing pharmacy is authorized to transfer medications between containers and that all compartments containing drugs and biologicals must be locked when not in use. These lapses in medication storage and handling had the potential to affect more than four residents in the facility.
Failure to Follow Menu and Serving Sizes During Meal Service
Penalty
Summary
Surveyors found that the facility did not follow its posted lunch menu or the required serving sizes for potatoes for residents eating both in the dining room and in their rooms. Specifically, residents in the dining room were not served the cut potatoes listed on the menu, and residents eating in their rooms on the first floor received only 2 ounces of potatoes instead of the required 4 ounces. The facility's Meal Distribution policy requires that all meals be assembled according to individualized diet orders, care plans, and preferences, but this was not followed during the observed meal service. During the lunch service, a dietary aide served pork with peppers and onions and mashed potatoes instead of the menu-listed cut potatoes and was unable to provide an explanation for the missing item. In the kitchen, a cook initially used a 2-ounce scoop to serve potatoes, providing only half the required portion, and only switched to a 4-ounce scoop after being prompted. The dietary manager confirmed that the correct menu and serving sizes were not followed for the meal service.
Deficient Food Handling and Sanitation Practices Observed
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as observed by surveyors during meal service. A dietary aide was seen plating food while not following proper hand hygiene protocols, including not changing gloves or performing hand hygiene after touching various surfaces and before handling ready-to-eat food. The aide also changed gloves without washing hands in between, and continued to handle food and food service items with potentially contaminated gloves. Additionally, the aide's hair was not fully contained within the required hair restraint, with a portion of hair hanging down the back, contrary to both facility policy and state food code requirements. Surveyors also observed that ice scoops were improperly stored inside or on top of ice in coolers on multiple units, rather than in a clean, protected location as required. The dietary manager confirmed that these practices did not align with facility policy or state regulations, and acknowledged that nursing staff may have contributed to the improper storage of scoops. These deficiencies had the potential to affect more than four residents in the facility.
Failure to Notify POAHC of Pharmacogenomic Testing and Obtain Proper Consent
Penalty
Summary
The facility failed to notify the Power of Attorney for Healthcare (POAHC) of pharmacogenomic testing performed on a resident with moderately impaired cognition and an activated POAHC. The resident, who had diagnoses including anxiety disorder, major depressive disorder, psychosis, and insomnia, was admitted with a BIMS score indicating moderate cognitive impairment. Despite the facility's policy requiring notification of changes in a resident's status to the resident's representative and physician, the POAHC was not informed about the pharmacogenomic testing, nor did they provide consent for it. Instead, the resident verbally approved the consent form provided by the laboratory company, and the form did not include the POAHC's signature or acknowledgment. Record review and interviews revealed that the facility could not determine which physician requested the testing, even though the order was signed by the Medical Director. The Medical Director was unaware of the specific testing for the resident and indicated that a blanket order process was used. The Nursing Home Administrator confirmed that there was no documentation of POAHC notification and acknowledged that the resident should not have given verbal consent without POAHC involvement. The POAHC only became aware of the testing after receiving insurance correspondence, and the resident was later discharged against medical advice due to care concerns.
Failure to Provide Scheduled ADL Care and Incomplete Documentation
Penalty
Summary
A deficiency occurred when a resident with spastic quadriplegic cerebral palsy and anxiety disorder did not receive assistance with activities of daily living (ADLs) as specified in their care plan. The resident was scheduled to receive weekly showers and required physical assistance for bathing, transfers, and toileting. However, documentation and staff interviews revealed that the resident did not receive weekly showers as planned, with only two showers documented during the resident's stay, and significant gaps of 12 to 16 days between showers. Additionally, staff reported that while the resident was checked and changed, they were not regularly transferred to the toilet as required by the care plan. Review of the resident's medical record showed inconsistent ADL documentation, with only 30 out of 71 shifts containing completed records for required ADL tasks such as transfers, toileting, and bathing. The facility's policies required that all showers, refusals, and assistance provided be documented, but records were incomplete, and staff confirmed that missing documentation indicated the task was either not performed or not recorded. The lack of consistent documentation and failure to provide scheduled care led to the deficiency.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically during medication administration for two residents. On April 1, 2025, an LPN was observed preparing and administering medications to two residents without performing hand hygiene beforehand, as required by the facility's Handwashing/Hand Hygiene policy. The LPN acknowledged during an interview that hand hygiene should have been completed prior to medication preparation and administration but confirmed it was not done. The Director of Nursing also confirmed that staff are expected to perform hand hygiene before these tasks.
Safety Lapses Lead to Immediate Jeopardy in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment for residents, leading to two significant incidents. In the first incident, a resident with dementia and aggressive behavior, who was under 1:1 supervision, accessed a loaded firearm from a CNA's purse. The CNA had brought the gun into the facility and left it in the resident's room while taking a break. The resident retrieved the gun and carried it onto a secured memory care unit, posing a potential threat to other residents. Staff intervened and removed the gun, but the incident highlighted a severe lapse in safety protocols. In the second incident, a resident with intact cognition suffered a third-degree cryogenic burn due to improper handling of a portable oxygen tank. The tank was placed on the foot pedals of the resident's wheelchair, leading to a leak that caused a burn on the resident's right ankle and heel. Despite the resident's complaints of pain, the wound was not properly monitored or treated until several days later, resulting in a severe burn that required surgical intervention and antibiotic treatment. Both incidents were classified as immediate jeopardy due to the potential for serious harm. The facility's failure to prevent these hazards and adequately supervise residents resulted in significant deficiencies in care. The incidents underscore the importance of adhering to safety protocols and ensuring that staff are properly trained to prevent such occurrences.
Removal Plan
- Notified the police and removed the employee and firearm from the building.
- Educated all staff on personal belongings, active violence training, and active shooter drills.
- Initiated psychosocial monitoring for all residents on the 500 unit.
- Initiated audits to ensure weapons are not brought into the facility.
- Educated licensed and certified staff on the facility's Oxygen Usage policy and procedure.
- Checked all resident and stock portable oxygen tanks to ensure proper function.
- Completed skin assessments on all residents who use portable oxygen tanks.
- Reviewed and/or revised the care plans of all residents at risk for oxygen burns.
Failure to Notify POA and Physician of Critical Incidents
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) and physician of significant incidents affecting the residents. One resident, who was on 1:1 supervision due to aggressive behavior, accessed a loaded gun from a staff member's purse and carried it onto a secured memory care unit. Despite the severity of the incident, the resident's POA was not informed. The Nursing Home Administrator confirmed that the police were notified, and the staff member was charged, but the POA was not updated about the incident. In another case, a resident with intact cognition and multiple health issues, including a right ankle soft tissue infection, experienced skin irritation when a portable oxygen tank was placed near their leg. The resident reported the irritation, and a reddened area was observed, but the physician and responsible party were not notified. The Director of Nursing and a Registered Nurse acknowledged that the new skin concern should have been documented and communicated to the relevant parties, but this was not done.
Failure to Provide Bed Hold Notice for Resident Transferred to ER
Penalty
Summary
The facility failed to provide a bed hold notice to a resident (R1) who was transferred to the emergency room (ER) by family members. R1, who had diagnoses including malignant neoplasms and repeated falls, was residing at the facility for rehabilitation services. On the day of the incident, R1 expressed feeling unwell and had not seen a physician, prompting family members to contact R1's hospital care team, who advised an ER visit. Despite the facility's policy requiring written bed hold information to be provided before hospital transfers, neither R1 nor the family received such notice. Interviews with staff revealed a lack of communication and awareness regarding the bed hold policy. The Registered Nurse (RN) and Licensed Practical Nurse (LPN) on duty did not discuss or offer a bed hold notice to R1 or the family. The Unit Manager (UM) was unaware of the situation and did not provide the necessary information. The Nursing Home Administrator (NHA) was uncertain if a bed hold notice was required, as the family initiated the hospital transfer. The medical record review confirmed the absence of a documented bed hold notice, indicating a deficiency in following the facility's policy.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was permitted to return after a hospital visit, which exceeded the bed-hold policy. The resident, who was admitted for rehabilitation due to increased falls and had diagnoses including malignant neoplasms and repeated falls, was taken to the emergency room by a family member after feeling unwell. Upon attempting to return to the facility, the resident was informed that they had been discharged and could not return without a new referral, despite the facility's policy indicating that residents should be allowed to return if their needs can be met. The incident involved a series of miscommunications and lack of documentation. The resident's family was not informed of the process for leaving or returning to the facility, and the facility staff did not provide a bed-hold notice when the resident was taken to the ER. The Director of Nursing noted that the resident was discharged against medical advice, but there was no discharge summary or interdisciplinary note to support this. The facility's regional office initially decided not to accept the resident back, but after intervention from an Ombudsman, the facility agreed to readmit the resident. Interviews with staff and family members revealed that there was confusion about the resident's status and the process for readmission. The Nursing Home Administrator was under the impression that the resident had left with all their belongings and was not returning, leading to the discharge. The facility's failure to communicate effectively with the resident and their family, as well as the lack of proper documentation, contributed to the deficiency in allowing the resident to return after hospitalization.
Inadequate Catheter Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate catheter care and monitoring for a resident with an indwelling catheter, leading to significant health complications. The resident had a Foley catheter inserted due to urinary retention, but from the time of insertion until a later date, staff did not monitor the resident's urine output or assess for genitourinary changes. This lack of monitoring and assessment resulted in the resident experiencing penile pain, increased confusion, low urine output, and a large amount of pus at the catheter site. The resident's medical record lacked documentation of urinary output, urine appearance, or genitourinary changes for a significant period. Additionally, urinary and catheter assessments were not completed on specific dates, despite the resident's complaints of pain and other symptoms. The resident was eventually transferred to the hospital, where it was discovered that the catheter was blocked and draining thick gray material, leading to diagnoses of urinary retention, a urinary tract infection, and acute kidney injury. Interviews with facility staff revealed that catheter drainage bags were supposed to be emptied every shift and documented, but there was no evidence of this documentation in the resident's medical record. The facility's guidelines for urinary indwelling catheter management were not followed, contributing to the resident's adverse health outcomes. The lack of proper catheter care and monitoring highlights a deficiency in the facility's care practices.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation, as evidenced by inadequate background checks for three out of nine staff members reviewed. Specifically, the facility did not conduct a thorough background check for a Dietary Aide (DA)-H, who had substantiated findings of caregiver misconduct and was prohibited from working in Department of Health Services (DHS) regulated facilities. DA-H also failed to report felony convictions on their Background Information Disclosure (BID) form. Despite these findings, DA-H was hired by a contracted company responsible for dietary services, and the facility's administration acknowledged that further investigation should have been conducted before employing DA-H. Additionally, the facility did not ensure timely completion of background checks for other staff members. A Certified Nursing Assistant (CNA)-J was hired without a Department of Justice (DOJ) letter or Government Findings Report until the date of the survey, and the facility's policy of completing background checks within 30 days was acknowledged as insufficient. Furthermore, the facility lacked documentation for DA-L's most recent hire date, with discrepancies in the BID form, DOJ letter, and Government Findings Report. These oversights indicate a failure to adhere to the facility's policy of conducting comprehensive background checks prior to employment.
Failure to Protect Resident from Verbal Abuse by Dietary Aide
Penalty
Summary
The facility failed to protect a resident, identified as R3, from verbal abuse by a dietary aide, DA-H. On November 2, 2024, multiple staff members witnessed DA-H verbally abusing R3 by calling them a derogatory name and threatening physical harm with R3's walker. The incident occurred when R3 attempted to use the microwave, leading to DA-H's aggressive behavior. Although no physical contact was made, the situation required several staff members to intervene and remove DA-H from the dining room. R3, who was not cognitively impaired and made their own healthcare decisions, reported feeling shocked and taken off guard by the incident. The facility's failure to conduct a thorough background check on DA-H contributed to the deficiency. DA-H, hired by a contracted third-party provider for dietary services, had a history of caregiver misconduct, including substantiated findings of misappropriation of client property. Despite this, DA-H was employed in a role involving direct contact with residents. The background check process, managed by the contracted company's corporate Human Resources department, failed to identify these issues, resulting in DA-H being cleared to work at the facility. The Nursing Home Administrator and Dietary Manager acknowledged that the background check contained evidence of misappropriation, which should have prompted further investigation before employing DA-H. The facility's policy required screening potential employees for a history of abuse, neglect, or exploitation, but this was not adequately followed. The incident was reported to local law enforcement and the State Agency, and the facility's investigation substantiated the abuse allegation.
Inadequate Supervision of Resident Requiring 1:1 Care
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R2, who required direct 1:1 supervision due to a history of yelling, threatening, and hitting peers and staff. R2's care plan, revised on 11/27/24, included interventions for 1:1 supervision to manage these behaviors and avoid triggers. However, on 1/7/25, the surveyor observed R2 without the required 1:1 supervision on multiple occasions, both in R2's room and in the dining room with other residents present. This lack of supervision was confirmed by CNA-C, who was assigned to supervise R2 from 6:00 AM to 6:00 PM. The facility had previously provided staff education on 11/19/24 regarding 1:1 supervision expectations, emphasizing that residents requiring such supervision should never be left alone and should always be within arm's length of staff. Despite this, the surveyor's observations indicated non-compliance with these guidelines. The Nursing Home Administrator confirmed that R2 was supposed to be under constant 1:1 supervision and acknowledged that the staff education was implemented following a previous incident where R2 was left unsupervised for approximately 10 minutes.
Resident Discharged Without Proper Planning or Medication
Penalty
Summary
The facility failed to allow a resident, identified as R1, to remain in the facility after returning from a hospital stay, despite the resident's plan to move into an apartment 11 days later. R1 was admitted to the hospital with congestive heart failure and chronic obstructive pulmonary disease exacerbations and returned to the facility stable for discharge. However, following an argument with staff, R1 was told to leave the facility and was discharged to a relative's home without medication or a proper discharge plan. The incident occurred after R1 returned from the hospital and was adjusting well to being back in the facility. On the day of the incident, the Nursing Home Administrator (NHA) and Social Services (SS) spoke with R1 about the discharge plan, which led to a confrontation. R1 was informed that they needed to find alternative accommodation until the apartment was ready, which resulted in a heated exchange. R1 refused to sign the Against Medical Advice (AMA) paperwork, and the facility did not provide R1 with medications upon discharge. Interviews with staff and the resident revealed that R1 was escorted out of the facility without a signed discharge plan or medication. The NHA admitted that R1 could have stayed in the facility until the apartment was ready, but this was not communicated to R1. The lack of proper discharge planning and communication led to R1 being discharged without necessary medications and a formal discharge plan, constituting a deficiency in the facility's care.
Failure to Provide Replacement Glasses for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary assistive devices to maintain vision, specifically replacement glasses after the resident's original glasses were lost within the facility. The resident, who had severe cognitive impairment and multiple eye-related diagnoses, including cataract, glaucoma, and retinopathy, was observed without glasses. The resident's family had filed grievances regarding the missing glasses, but the facility's grievance file lacked documentation of corrective action, resolution, or follow-up. Interviews with facility staff revealed that the Grievance Officer was aware of the missing glasses and the filed grievances but did not take action to obtain replacements, citing a lack of concern from the resident's Power of Attorney for Healthcare (POAHC). However, the POAHC later expressed the need for the resident to have glasses due to their diabetes and vision requirements. The Nursing Home Administrator acknowledged that new glasses should have been obtained, indicating a lapse in the facility's follow-up process.
Infection Control Deficiency: Improper Handling of Linens
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of clean towels by a Certified Nursing Assistant (CNA). On the specified date, the CNA was observed carrying clean towels pressed against their scrub top while delivering them to residents' rooms, including two specific residents. This action was contrary to the facility's infection control policy, which mandates that linens be handled in a manner that prevents the transfer of microorganisms. The CNA was corrected by a Licensed Practical Nurse (LPN) for not following the proper protocol, which includes using a cart to transport linens. The CNA admitted to delivering towels inappropriately and acknowledged the need for further training. The LPN confirmed the CNA's deviation from the facility's protocol and emphasized the importance of using a cart for transporting linens to prevent contamination. The incident highlights a lapse in adherence to the facility's infection control procedures, specifically regarding the handling and transportation of clean linens, which is crucial for preventing the spread of infections among residents.
Significant Medication Errors in Seizure Management
Penalty
Summary
The facility failed to ensure that two residents, identified as R607 and R605, were free from significant medication errors. R607, who has a diagnosis of epilepsy, did not receive prescribed doses of Lacosamide and Keppra multiple times over several months. This resident was transferred to the hospital for seizures after missing several doses of these medications. The facility's medication administration records and notes indicated that the medications were often unavailable, and there was a lack of clarity on why the medications were not administered as ordered. R605, also diagnosed with epilepsy, did not receive Clobazam as prescribed on multiple occasions. The medication was available in the facility, but it was not administered due to staff not knowing where to find it or what it was. This resulted in 17 missed doses out of 90 opportunities. Interviews with facility staff revealed that the medication was kept in a locked narcotic drawer, and there was a lack of awareness among staff, particularly agency staff, about its location. The facility's policies require medications to be administered safely, timely, and as prescribed. However, the repeated failures to administer seizure medications as ordered for both residents indicate a significant lapse in adherence to these policies. The facility's staff, including the Director of Nursing and Unit Manager, were unable to provide adequate explanations for the medication errors, highlighting a systemic issue in medication management and staff training.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to provide two residents, R600 and R601, the opportunity to participate in the development and implementation of their person-centered care plans. R600, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus and Major Depressive Disorder, was found to have no documentation in their electronic medical record indicating participation in care conferences since admission. Despite being cognitively intact, as evidenced by a BIMS score of 15, R600 and their representative were not included in interdisciplinary meetings to discuss ongoing care. R601, who was admitted with severe cognitive impairment and other health issues, also did not have adequate care conferences. The last documented care conference for R601 was held in March, with no further meetings documented before their discharge in August. Although R601's care plan was revised multiple times, there was no evidence that these changes were communicated to R601 or their Power of Attorney. The facility's policy requires initial and ongoing care management meetings to involve the patient and their representative, but these were not conducted as required. The facility acknowledged the issue, noting that the social worker responsible for care conferences had left, and an audit revealed that care conferences were not held quarterly as mandated. This lack of adherence to policy resulted in the residents not being involved in their care planning process.
Failure to Notify Resident's Representative of Treatment Changes
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's treatment and condition, as required by their policy. The resident, identified as R600, had several instances where their representative was not informed of important medical updates. These included the rescheduling of a colonoscopy, a transfer to the emergency room for leg swelling, and changes in medication and lab orders related to thyroid and potassium levels. The facility's policy mandates immediate notification to the resident and their representative in cases of significant treatment alterations or changes in condition. Despite this, there was no documentation in R600's electronic medical record indicating that the representative was informed of these changes. The resident expressed a desire for their representative to be involved in all medical decisions, highlighting the importance of this communication. Interviews with the resident and facility staff revealed a lack of clarity regarding the resident's power of attorney, which contributed to the failure in communication. The Nursing Home Administrator acknowledged the oversight and agreed that the representative should have been notified. The surveyor noted the absence of documentation for the hospital transfer and the lack of notification to the resident's representative about the changes in treatment and condition.
Failure to Resolve Resident's Grievance Regarding Uncomfortable Sleeping Arrangements
Penalty
Summary
The facility failed to adequately address and resolve a grievance filed by a resident, identified as R609, who has Amyotrophic Lateral Sclerosis (ALS) and other medical conditions. The grievance, initiated on 9/3/24, was related to the resident's request for a comfortable mattress or a recliner for sleeping, as the current bed was uncomfortable. The facility's response was to inform the resident that recliners were not provided and that an air mattress was not an option due to the absence of wounds. The resident was advised to contact their physician about the air mattress, but no alternative solutions were offered by the facility. The resident, who is dependent on assistance for mobility and at high risk for pressure injuries, was observed by the surveyor on 9/17/24 sitting in a narrow wheelchair, which she described as uncomfortable and restrictive. Despite the resident's ongoing discomfort and inability to move freely, the facility did not provide a new mattress or bed, resulting in the resident sleeping in the wheelchair. The Assistant Nursing Home Administrator (ANHA) acknowledged the situation but stated that the resident did not qualify for an air mattress and that no other bed options were available. The facility's documentation and communication with the Board of Aging & Long Term Care (BOALTC) indicated a misunderstanding of the resident's needs, focusing on the absence of wounds rather than the resident's comfort and mobility issues. The facility's grievance resolution process was inadequate, as it did not involve consulting the resident's physician or exploring other options for a comfortable sleeping arrangement. As of the survey exit date, the grievance remained unresolved, and the resident continued to sleep in the wheelchair.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report two separate incidents of injuries of unknown origin involving two residents to the State Survey Agency in a timely manner. The first incident involved a resident, R606, who was found with bruising and swelling to the right eye. Despite the injury being noted by an LPN and reported to the Assistant Director of Nursing and Director of Nursing, it was not immediately reported to the Nursing Home Administrator or the State Survey Agency. Conflicting statements from staff regarding the cause of the injury were noted, and the facility did not have documentation of any incident that could explain the injury. The second incident involved another resident, R603, who was found to have a fracture in the left hand. Initially, the swelling was thought to be due to gout, but an X-ray later revealed a fracture. The facility conducted an investigation and determined a probable cause for the injury, but failed to submit a Self Report to the State Agency before the investigation was initiated. The Director of Nursing acknowledged that a Self Report should have been filed for the injury of unknown origin. Both incidents highlight a deficiency in the facility's adherence to its policy on reporting suspected abuse, neglect, or injuries of unknown origin. The policy requires immediate reporting of such incidents to the appropriate authorities, but this was not followed in these cases. The lack of timely reporting and conflicting accounts of the incidents suggest a breakdown in communication and procedure within the facility.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving a resident, identified as R606, who was found with bruising and swelling to the right eye. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of such incidents, including obtaining statements from all involved staff. However, the investigation was incomplete as the facility did not obtain statements from all staff who had contact with the resident prior to the discovery of the injury, leading to conflicting accounts of how the injury occurred. R606, a resident with vascular dementia, anxiety disorder, epilepsy, hemiplegia, hemiparesis, and paroxysmal atrial fibrillation, was noted to have a swollen and bruised right eye. The resident has both short and long-term memory impairment and requires significant assistance with daily activities. Despite having a 1:1 staff assigned since admission, there was no documentation of a fall or incident that could explain the injury. The facility's Director of Nursing (DON) reported that the resident might have hit their head on the bed frame while rolling on the mat, but this was not confirmed by the staff involved. The investigation was further compromised by the lack of documentation and conflicting statements from the staff. The LPN who worked on the day of the incident did not report it or complete a fall packet, and the CNA assigned to the resident provided a different account of the events. The facility did not submit a documented investigation to the State Survey Agency, and the surveyor noted the absence of a thorough assessment of the injury. The facility's failure to obtain comprehensive statements and documentation resulted in an incomplete investigation of the incident.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents, R602 and R606, were revised to reflect their current care needs. For R602, after a fall incident on 7/30/24, the interdisciplinary team determined an intervention to offer the resident to get up and dressed for the day if awake. However, this intervention was not added to R602's care plan for falls, despite the resident having a history of falls and being at risk for falls due to dementia-related weakness. The Director of Nursing acknowledged that the intervention should have been included in the care plan. For R606, the care plan and Kardex were not individualized to address the resident's specific care needs. R606, who has diagnoses including vascular dementia and epilepsy, demonstrated behaviors such as striking out at staff and pulling at the feeding tube. The care plan did not include interventions for these behaviors, nor did it document the use of a mat on the floor or the resident's elopement risk. Additionally, the Kardex, which guides CNAs in providing care, lacked documentation of a continuous 1:1 supervision for safety reasons, which was verbally confirmed by staff. The surveyor noted that the facility's policy requires care plans to be revised with changes in the resident's condition, but this was not adhered to for R606. Interviews with staff, including the Director of Nursing and Unit Manager, confirmed that the care plan and Kardex should have been updated with specific interventions to address R606's needs. The failure to update these documents resulted in a lack of clear guidance for staff on how to manage the residents' care effectively.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident, identified as R601, maintained acceptable parameters of nutritional status, resulting in severe weight loss over a period of seven months. Despite the facility's policy on nutritional status management, which requires interventions to maintain or improve nutritional needs, the interdisciplinary team did not implement new interventions or notify the physician about the resident's significant weight loss. The resident's care plan included goals and interventions to maintain adequate nutritional status, but these were not effectively monitored or adjusted in response to the resident's declining weight. R601, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, and bipolar disorder, experienced a weight loss of 13.16% from January to August. The facility's dietician noted the weight decline in progress notes but did not alert the physician or add new interventions to the care plan. The dietician's analysis was based on a reweight that was inconsistent with other recorded weights, leading to a lack of acknowledgment of the ongoing weight loss. Additionally, the resident's dietary preferences and the impact of family-provided food were not adequately addressed in the care plan. Interviews with facility staff revealed inconsistencies in the monitoring and assistance provided to R601 during meals. Certified Nursing Assistants reported that the resident sometimes refused to eat or required assistance, but there was no consistent approach to addressing these issues. The speech therapist's recommendations regarding feeding when the resident was sleepy were not incorporated into the care plan. The facility's failure to monitor and respond to the resident's nutritional needs resulted in a deficiency in maintaining the resident's health and nutritional status.
Deficiency in PRN Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that a resident, identified as R606, was free from unnecessary medications, specifically regarding the use of a PRN order for Ativan, an anti-anxiety medication. The report highlights that the PRN order for Ativan did not have a documented rationale in the resident's medical record indicating the duration for the PRN order beyond 14 days, as required by the facility's policy. The policy mandates that PRN orders for psychotropic medications should be discontinued after 14 days unless the prescriber documents a rationale for extending the order and specifies a duration for the extended treatment. R606 was admitted with multiple diagnoses, including Vascular Dementia, Anxiety Disorder, and others, and was noted to have both short and long-term memory impairment, severely impaired decision-making skills, and various behavioral issues. The resident's comprehensive care plan included the use of psychotropic medications for behavior management. Despite this, the Ativan PRN order was being administered regularly without proper documentation of the rationale, stop date, or end date, and without a re-evaluation prior to the 14-day limit. The surveyor's review of the resident's electronic medical record and psychiatric evaluation notes revealed that there was no documentation of a stop date or end date for the PRN Ativan order. The evaluations conducted by the Psychiatric Mental Health Nurse Practitioner did not document any behavior trends or provide a rationale for the continued use of the medication. The facility's failure to document and re-evaluate the necessity of the PRN Ativan order led to the deficiency noted in the report.
Resident Sleeps in Wheelchair Due to Uncomfortable Bed
Penalty
Summary
The facility failed to provide functional furniture appropriate to the resident's needs, specifically a comfortable mattress for a resident identified as R609. R609, who has multiple diagnoses including Amyotrophic Lateral Sclerosis (ALS) and is at high risk for pressure injuries, reported discomfort with her current bed and requested a new mattress. Despite filing a grievance and expressing her discomfort, the facility did not provide a new mattress or alternative sleeping arrangement, leading R609 to sleep in her wheelchair. The resident's grievance, filed on 9/3/24, indicated that the bed was uncomfortable, and she requested a recliner to sleep in. The facility's response was that no other mattress options were available, and an air mattress was not provided because R609 did not have any wounds. The Assistant Nursing Home Administrator (ANHA) acknowledged the resident's complaint but stated that the facility's mattresses were all the same and that the resident did not qualify for an air mattress. The grievance was considered resolved by the facility, despite the resident's continued discomfort and lack of a suitable sleeping arrangement. The facility's communication with the Board of Aging & Long Term Care (BOALTC) revealed that the resident's bed was not broken, but the footboard was out of its bracket. The facility maintained that the resident was sleeping in her wheelchair due to breathing issues and discomfort in her bed. Despite the resident's ongoing complaints and the BOALTC's involvement, the facility did not provide a new bed or mattress, resulting in the resident continuing to sleep in her wheelchair, which was not documented in her care plan.
Failure to Provide Comprehensive Social Services Leads to Resident Injury
Penalty
Summary
The facility failed to provide comprehensive medically-related social services to a resident, identified as R124, which resulted in immediate jeopardy. R124, who had a history of anxiety and depression, was admitted to the facility following a stroke. Despite assessments indicating no cognitive impairment, the facility did not reassess the need for the activation of the power of attorney for healthcare, which was initially activated due to delirium in a hospital setting. The facility also failed to explore alternatives to the antidepressant Sertraline, which R124 consistently refused to take, and did not develop a plan of care for supervising R124 when agitated and expressing a desire to leave the facility. R124 expressed a desire to leave the facility multiple times and attempted to do so, setting off alarms and eventually using bed sheets to climb out of a second-story window, resulting in serious injuries. The facility did not adequately address R124's discharge planning, as there was no evidence of a comprehensive discharge plan or reassessment of R124's cognitive status to assist in establishing an individualized discharge plan. The facility also failed to provide interdisciplinary care to address R124's medication needs, discharge requests, and anxious behaviors, and did not document or discuss deactivating the power of attorney. The facility's lack of action in addressing R124's desire to live at home, assessing R124's ability to make their own decisions, and directing their care led to increased anxiety, isolation, and behaviors indicating a desire to leave. This culminated in R124 taking extreme measures to exit the facility, resulting in significant physical harm. The facility's failure to provide necessary social services and care planning created a situation of immediate jeopardy for R124.
Removal Plan
- R124 sent out to hospital
- MD and POA notified
- Complete investigation with full RCA (root cause analysis)
- Check resident's wanderguard device and ensure it is functioning properly
- Check all wanderguards and wanderguard/alarm doors for functionality
- Education provided to Social Service staff on Medical Social Services, Discharge Planning, Care Conference and POA activation
- Staff educated on Wandering and Elopement, and Behavior Monitoring
- Care plans will be reviewed and updated as needed
- Care conferences addressing discharge planning will be scheduled for those who express desire to leave
- Review by DON/designee to ensure accurate, appropriate plan of care in place
- Elopement and wandering binders were reviewed and updated as needed
- Residents who are not-interviewable and need increased supervision will be put on 24-hour board and monitored closely
- DON or designee will conduct audits to ensure care conferences were scheduled and held to discuss discharge planning
- Audits will be reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education is needed
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident, identified as R109, who developed a Deep Tissue Injury (DTI) while under their care. R109 was admitted with a stage 2 pressure ulcer and was at risk for pressure ulcers due to conditions such as traumatic spinal cord dysfunction and paraplegia. Despite these risks, the facility did not conduct or document the required weekly skin checks on multiple occasions from March to June 2024, as outlined in their policy. This lack of monitoring contributed to the development of a new DTI on the resident's left ankle. The facility's policy required individualized care plans to be developed and updated with any change in condition, including interventions for skin integrity. However, the facility did not update R109's care plan or implement necessary interventions after the resident's readmission from the hospital in March 2024. The facility also failed to document any assessment or treatment for the left ankle DTI until late June 2024, despite the resident's condition requiring attention. Additionally, there was a discrepancy in the documentation regarding the resident's willingness to wear pressure-relieving boots, which were part of the preventive measures. The facility's records indicated that the resident refused to wear them, but the resident's MDS did not show any behaviors related to care rejection. This inconsistency, along with the lack of timely assessments and interventions, highlights the facility's failure to adhere to professional standards of practice in managing the resident's pressure injuries.
Inadequate Infection Control and Environmental Maintenance
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program based on current standards of practice, which compromised the safety of the environment and increased the risk of communicable diseases and infections among all 148 residents. The Water Management Plan (WMP) was outdated and did not reflect changes in program members, lacked knowledgeable team members, and failed to identify control measures for Legionella growth and spread. Additionally, the WMP did not specify acceptable control limits or corrective actions when limits were not met, and relevant tasks were not formally documented. The facility's Infection and Control Program Surveillance was inadequate, as it did not provide monthly infection percentage rates for each infection type, nor did it separate urinary tract infections (UTIs) into catheter-associated and non-catheter-associated categories. Surveillance documentation was missing for several months, and there was no evidence of interventions implemented for increased UTI rates. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them, as recommended by the CDC and per the facility's policy. This was evident in the cases of residents with catheters and wounds who did not have precaution signs or personal protective equipment (PPE) available. Environmental issues in the facility's laundry area further contributed to the deficient infection control program. Observations revealed washers coated in crusty matter, water dripping from the ceiling, and grease on the floor. Maintenance tasks related to the laundry equipment were not adequately documented, and issues such as a leaking grease tank were not promptly addressed due to financial constraints. These lapses in maintaining a clean and safe environment further exacerbated the facility's failure to uphold an effective infection prevention and control program.
Facility Fails to Maintain Safe Equipment Conditions
Penalty
Summary
The facility failed to maintain mechanical and electrical equipment in safe operating condition, as observed by the surveyor. A leaking grease tank from the kitchen was found next to the dryers in the laundry area, which was reportedly caused by staff hitting the pipe with carts. The Maintenance Assistant (MA) indicated that the tank needed to be emptied before repairs could be made, but the contractor required immediate payment, which had not been arranged. This issue had been known for several weeks, and the Maintenance Director was in the process of obtaining quotes from different companies to address the problem. Additionally, the surveyor noted a significant accumulation of lint in the dryer vent, which was confirmed by the Life Safety Engineer who observed about one inch of debris covering the outside vent. The maintenance task log indicated that lint removal and inspection for water leaks were completed earlier in the month, yet a washing machine for residents' personal clothing was leaking water, a problem that had persisted for about a week. Despite these ongoing issues, no further information was provided to explain why the facility did not maintain the equipment in safe operating condition.
Lack of QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that all staff received the mandatory Quality Assessment and Performance Improvement (QAPI) program training, specifically for two of the five sampled Certified Nursing Assistants (CNAs). This deficiency was identified during a review of the training records for CNA-II and CNA-JJ, which revealed no documentation of their participation in the QAPI program training. The Nursing Home Administrator (NHA) confirmed the absence of this training for the two CNAs and acknowledged that the facility was in the process of providing the necessary QAPI training to all CNAs. This oversight has the potential to impact the 148 residents who may receive care from these CNAs.
Lack of Compliance and Ethics Training for CNAs
Penalty
Summary
The facility failed to ensure that two of five sampled Certified Nursing Assistants (CNAs) received annual training on the facility's compliance and ethics program. This deficiency was identified during a survey conducted on July 12, 2024. The surveyor reviewed the training records of CNA-II and CNA-JJ and found no documentation indicating that they had received the required training. When the Nursing Home Administrator (NHA) was asked for documentation, it was confirmed that the facility had not provided the necessary training to these CNAs. The lack of training has the potential to affect the 148 residents who reside at the facility and may receive care from these CNAs.
Failure to Complete Required Background Checks for Staff
Penalty
Summary
The facility failed to properly complete required background checks for two employees, which could potentially affect the care provided to residents. Specifically, the facility did not complete a Background Information Disclosure (BID) form, Department of Justice (DOJ) form, and Integrated Background Information System (IBIS) form upon hiring a Certified Nursing Assistant (CNA) and did not update these forms for an Activity Aide within the required four-year period. The CNA was hired in November 2023, but the BID was not completed until February 2024, and the DOJ and IBIS forms were not completed until June 2024. Similarly, the Activity Aide, hired in August 2018, had their BID, DOJ, and IBIS forms completed in mid-2018, but these were not updated in the last four years as required. During the survey, the Human Resources representative acknowledged the requirement to complete these forms every four years but did not provide an explanation for the oversight. The Nursing Home Administrator and Director of Nursing were informed of the deficiency, and they confirmed the requirement for these forms to be completed every four years. However, no additional information was provided to explain why the facility failed to comply with these requirements for the two staff members.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide the required written transfer notices to residents and their representatives when residents were transferred to a hospital. This deficiency was identified in the cases of ten residents, all of whom were transferred without receiving the necessary documentation. The Assistant Director of Nurses confirmed that the written transfer notices were not sent with the residents, as they were part of a bed-hold form that was not included in the transfer process. The surveyor's review of medical records revealed that none of the ten residents had documentation of receiving the transfer notices. These residents had various medical conditions, including prostate cancer, anemia, repeated falls, anxiety disorder, vascular dementia, major depressive disorder, cerebral infarction, severe protein-calorie malnutrition, end-stage renal disease, and mild cognitive impairment. Despite these conditions and the need for hospitalization, the facility did not provide the required notices, which should have been documented in the residents' medical records. During the survey, the Nursing Home Administrator, Director of Nurses, and Regional Nurse Consultant were unable to provide additional information or documentation to explain the absence of transfer notices. The surveyor repeatedly requested the missing documentation, but the facility confirmed that no such records existed for the transfers in question. This lack of compliance with transfer notice requirements was consistent across all reviewed cases, indicating a systemic issue within the facility's procedures.
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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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