Brewster Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Appleton, Wisconsin.
- Location
- 3300 W Brewster St, Appleton, Wisconsin 54914
- CMS Provider Number
- 525574
- Inspections on file
- 20
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Brewster Village during CMS and state inspections, most recent first.
A resident admitted with a left humerus fracture, weakness, and identified fall risk had a care plan requiring that the call light be kept within reach. During a night shift, a CNA assisted the resident to the bathroom and into a recliner but left the room call light clipped to the bed several feet away and did not apply the resident’s personal call device, leaving no accessible means to request help. The cognitively intact resident, who typically used the call light and had not previously self-transferred, attempted an unassisted transfer to the bathroom, resulting in an unwitnessed fall. The resident was later found on the floor with the call light out of reach and was hospitalized, where imaging showed a worsened comminuted left humerus fracture, an acute to subacute L1 compression fracture, and a scalp hematoma, ultimately requiring surgical repair of the shoulder.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with a preference for Spanish and interpreter services was not consistently provided with these services, leading to communication barriers. The resident's care plan did not address the language barrier, and staff often relied on gestures or family members for translation. This resulted in unmet needs and misunderstandings, such as difficulty in requesting medication and receiving disliked food items.
The facility failed to ensure call lights were within reach for three residents, including one with moderately impaired cognition and hand contractures, another who was severely cognitively impaired, and a third with moderate cognitive impairment. Despite staff acknowledging the issue, no alternative notification devices were provided, and systemic solutions were lacking.
A resident with multiple health conditions developed skin wounds that were identified by nursing staff but not reported to the physician until several days later, contrary to the facility's policy. The wounds, initially assessed as moisture-associated skin damage, were later diagnosed as unstageable pressure injuries. Interviews with staff confirmed that the physician should have been notified immediately upon discovery of the wounds.
A facility failed to provide necessary care for a resident requiring oxygen therapy. The resident, diagnosed with congestive heart failure, dementia, and pneumonia, had a physician order for oxygen but lacked a care plan for its use. The facility's policy required changing oxygen tubing after a respiratory infection, but there was no documentation of this being done. Observations and staff interviews confirmed the deficiency, as the resident's oxygen tubing change could not be verified.
A resident with end-stage renal disease and dependence on dialysis did not have a dialysis care plan, and facility staff failed to monitor the resident's fistula or assist with personal hygiene before dialysis appointments. The Director of Nursing acknowledged the oversight, noting that the care plan should have included dialysis and fistula monitoring.
A resident with multiple health conditions, including end-stage renal disease, was found with a tube of 1% hydrocortisone cream in their room without a self-administration assessment. The facility's policy requires such an assessment to ensure safe medication storage and administration, but this was not conducted, as confirmed by the DON.
A resident with a history of brain dysfunction and bipolar disorder was prescribed psychotropic medications, including diazepam and quetiapine fumarate, without adequate monitoring for adverse reactions. The facility's policy required monitoring for effectiveness and side effects, but the resident's medical record, MAR, and care plan lacked documentation of such monitoring. Interviews with nursing staff confirmed the absence of monitoring interventions, highlighting a deficiency in adhering to the facility's policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies. A CNA did not follow proper hand hygiene and glove-changing protocols during incontinence care for a resident with severe cognitive impairment. Two CNAs failed to wear required PPE while repositioning a resident on Enhanced Barrier Precautions. Additionally, a resident with pneumonia was not placed on droplet precautions despite exhibiting symptoms, highlighting lapses in infection control measures.
The facility did not offer the PCV20 vaccine to two residents with Alzheimer's dementia, despite CDC guidelines recommending it. One resident had previously declined other pneumococcal vaccines, while the other had received earlier versions but not the PCV20. The DON confirmed the oversight, acknowledging the vaccine should have been offered.
Failure to Maintain Accessible Call Light Leads to Resident Fall and Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for one resident at risk for falls. The resident was admitted with a left humerus fracture, weakness, and pain, and an admission fall risk assessment identified the resident as being at risk for falls. The care plan noted a potential for falls due to a history of falls and a recent left shoulder fracture and included an intervention to ensure the resident’s call light was within reach. On the night prior to the fall, a CNA assisted the resident to the bathroom and then into a recliner. The CNA left the room call light secured to the bed, approximately four feet from the recliner and out of the resident’s reach, and did not place the resident’s wrist call light on the resident. The resident had intact cognition and was known to consistently use the call light and had not self-transferred previously during the stay. At approximately 6:00 AM, the resident self-transferred to the bathroom without assistance, resulting in an unwitnessed fall in the room. Staff became aware of the fall after a family member called the facility, having been texted by the resident that help was needed. When the RN assessed the resident, the resident was found on the floor with pain in the left arm, the room call light clipped to the bed and out of reach, and the wrist call light in the nightstand. Hospital evaluation following the fall revealed a worsened comminuted fracture of the left humerus, an acute to subacute L1 compression fracture, and a scalp hematoma, and the resident later underwent surgery for the left humerus fracture.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Provide Interpreter Services for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, whose primary language is Spanish, was fully informed and able to participate in medical treatment and decisions in a language they could understand. The resident, who was responsible for their own healthcare decisions, expressed a preference for interpreter services to communicate medical treatment needs. However, these services were not consistently provided, and the resident's care plan did not address the language barrier. The resident's medical record indicated a preference for Spanish and the use of an interpreter, but the care plan failed to include this information. Social Services progress notes documented the need for an interpreter, yet communication with the resident often relied on family members or gestures. The resident reported difficulty in communicating needs, such as requesting medication for itchiness, and was not informed on how to request an interpreter. Interviews with staff revealed that while interpreter services were available, they were not consistently utilized. The Director of Nursing acknowledged that the resident's care plan did not address the language barrier, and staff often relied on simple questions or the resident's daughter for translation. The resident's inability to communicate effectively led to unmet needs and misunderstandings, such as receiving disliked food items.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 83, who had moderately impaired cognition and bilateral hand contractures, was observed multiple times without a call light within reach. Despite the resident's inability to reach or use the call light, no alternative notification device was provided. Staff acknowledged the oversight but did not implement a solution to ensure the resident could call for assistance. Similarly, Resident 80, who was severely cognitively impaired and unable to mobilize independently, was found without a call light within reach while seated in a Broda chair. Although the resident could press the call light when it was placed in their lap, staff had not considered alternative call light options. Resident 93, with moderate cognitive impairment and a care plan indicating the need for a call light within reach, was also observed without access to a call light. Staff confirmed the oversight and repositioned the call light, but no systemic solution was in place to prevent recurrence.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident, identified as R56, in a timely manner. R56, who had a history of urinary tract infection, neurocognitive disorder with Lewy bodies, dementia, type 2 diabetes, and erythema intertrigo, was admitted to the facility with moderate cognitive impairment. On November 26, 2024, nursing staff identified two small skin shearing areas on R56's coccyx, which were initially assessed as moisture-associated skin damage due to incontinence. Preventative measures, including barrier cream and repositioning, were implemented, but the physician was not informed of the wounds until December 2, 2024, when they were diagnosed as unstageable pressure injuries. Interviews with facility staff, including a wound care certified RN and the Director of Nursing, confirmed that the physician should have been notified immediately upon discovery of the wounds on November 26, 2024. The facility's policy on Notification of Change in Condition/Treatment requires significant changes in a resident's status to be reported to the physician promptly, which was not adhered to in this case. This delay in communication represents a deficiency in the facility's adherence to its own policies and procedures regarding timely notification of changes in a resident's condition.
Failure to Provide Adequate Oxygen Therapy Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident requiring oxygen therapy. The resident, who had diagnoses including congestive heart failure, dementia, and pneumonia, had a physician order for 2-6 liters per minute of oxygen via nasal cannula. However, the resident's medical record did not include a care plan for oxygen use, which is a critical component of managing their respiratory needs. Additionally, the facility's policy required that nasal cannula and oxygen tubing be changed when a resident had a recent respiratory infection, but there was no documentation indicating that the resident's tubing was changed after being diagnosed with pneumonia. Observations and interviews conducted by the surveyor revealed that the resident was using oxygen at 2 liters per minute, but the staff could not verify when the oxygen tubing was last changed. The Director of Nursing acknowledged that the resident should have had a care plan for oxygen therapy and that the oxygen tubing should be changed every 7 days and after a respiratory infection. This lack of adherence to the facility's policy and the absence of a care plan for oxygen therapy contributed to the deficiency identified during the survey.
Failure to Provide Appropriate Dialysis Care and Services
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R99, who required such services. R99, who was admitted with diagnoses including acute kidney failure, chronic respiratory failure, type 2 diabetes, end-stage renal disease, and dependence on renal dialysis, did not have a dialysis care plan in place. The facility's Dialysis Coordination policy required monitoring of dialysis access sites and initiation of a hemodialysis care plan, which was not done for R99. The resident's care plan, dated 7/16/24, did not include any mention of dialysis or the presence of a right arm fistula, which is critical for dialysis treatment. Interviews with R99 and the Director of Nursing (DON) revealed that facility staff did not consistently assist R99 with personal hygiene before dialysis appointments, and they were unaware of the need to avoid checking blood pressure on the arm with the fistula. R99 reported that dialysis staff monitored the fistula, but facility staff did not. The DON acknowledged that the care plan should have included dialysis and fistula monitoring, and that CNAs should be aware of dialysis appointments and the need to avoid using the right arm for blood pressure checks.
Failure to Conduct Self-Administration Assessment for Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R99, who was observed with a tube of 1% hydrocortisone cream stored under their refrigerator. The facility's policy on self-administration of medications requires an assessment by the Interdisciplinary Team to determine if a resident can safely self-administer medication and ensure safe storage. However, R99's medical record did not contain any such assessment, indicating a lapse in following the facility's policy. R99, who was admitted with diagnoses including acute kidney failure, chronic respiratory failure, type 2 diabetes, end-stage renal disease, and dependence on renal dialysis, had a BIMS score indicating no cognitive impairment and was responsible for their medical decision-making. During an interview, R99 and their daughter indicated that the daughter applied the cream during visits. The Director of Nursing confirmed that no self-administration assessment had been conducted for R99, and therefore, medications should not have been present in the resident's room.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for a resident prescribed psychotropic medications, which included diazepam, quetiapine fumarate, and mirtazapine. The resident, who had a history of non-traumatic brain dysfunction, insomnia, bipolar disorder, and severe unspecified dementia with agitation, was not monitored for adverse reactions to these medications. The facility's policy required that residents receiving psychotropic medications be monitored to evaluate the effectiveness and potential side effects of the medications, but this was not documented in the resident's medical record. During the survey, it was found that the resident's medical record, Medication Administration Record (MAR), and care plan lacked any documentation of monitoring interventions for adverse reactions to the psychotropic medications. Interviews with the Registered Nurse and the Director of Nursing confirmed the absence of such monitoring interventions in the resident's medical record, indicating a failure to adhere to the facility's psychotropic drug monitoring policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Certified Nursing Assistant (CNA)-C did not follow proper hand hygiene and glove-changing protocols while providing incontinence care to a resident with severe cognitive impairment and a history of urinary tract infections. CNA-C used the same gloves to clean the resident's buttocks and apply barrier cream, then donned a clean glove without sanitizing the hand, compromising infection control measures. Another deficiency was noted with a resident on Enhanced Barrier Precautions (EBP) due to a urostomy. CNAs M and N failed to wear the required gowns and gloves while repositioning the resident, despite the presence of an EBP sign on the door. The Director of Nursing confirmed that repositioning is considered high-contact care, and EBP should be used for residents with indwelling devices or wounds, which was not adhered to in this case. Additionally, a resident diagnosed with pneumonia and exhibiting symptoms such as coughing up phlegm was not placed on droplet precautions as required. The resident was initially on contact precautions, but these were removed despite ongoing symptoms. The Director of Nursing acknowledged that droplet precautions should have been implemented given the resident's condition and symptoms, highlighting a lapse in following appropriate transmission-based precautions.
Failure to Offer PCV20 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as R80 and R36, were offered the PCV20 vaccine as recommended by the CDC guidelines. R80, who was admitted with Alzheimer's dementia and had severely impaired cognition, had previously declined the PCV13 and PPSV23 vaccines in 2021. However, there was no documentation in R80's medical record indicating that the PCV20 vaccine was offered or administered. Similarly, R36, also diagnosed with Alzheimer's dementia and having moderately impaired cognition, had received the PCV13 and PPSV23 vaccines in the past but was not offered the PCV20 vaccine as per the CDC's updated recommendations. The Director of Nursing (DON) confirmed during an interview that both residents were not offered the PCV20 vaccine, acknowledging that it should have been provided according to the CDC guidelines. This oversight in offering the PCV20 vaccine to residents who had either declined previous vaccines or had received earlier versions without completing the updated vaccination schedule led to the deficiency noted by the surveyors.
Latest citations in Wisconsin
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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