Burlington Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Wisconsin.
- Location
- 677 E State St, Burlington, Wisconsin 53105
- CMS Provider Number
- 525482
- Inspections on file
- 38
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Burlington Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not consistently offer alternate meal options of equal nutritional value to residents who declined the main meal, and failed to post the Always Available Menu as required. Multiple residents reported not being offered alternatives for vegetables or starches, and staff confirmed that only one alternate entrée was available per meal. These actions were not in accordance with facility policy or regulatory expectations.
Surveyors identified multiple deficiencies in food storage and preparation, including a walk-in freezer with excessive ice buildup, brown lettuce with an unreadable date, dirty fans in the food prep area, and dietary staff preparing food without required beard restraints. Facility staff were aware of these issues but did not address them prior to the survey.
The facility did not electronically submit complete and accurate direct care staffing information to CMS, as required, using payroll and other verifiable data sources.
Staff did not consistently implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, as required by facility policy. PPE and EBP signage were missing for multiple residents, and staff provided high-contact care activities such as wound care, catheter care, and tube feeding without donning gowns or gloves. Leadership and staff interviews revealed confusion and inconsistent application of EBP, and care plans lacked instructions for PPE use. Additionally, the only sink in the contaminated laundry area was non-functional, preventing proper hand hygiene after handling soiled laundry.
A widespread fly infestation was observed throughout the facility, with multiple residents and staff reporting persistent issues in resident rooms, hallways, dining areas, and the kitchen. Residents described using personal items to swat at flies and purchasing their own traps, while surveyors observed flies landing on food and residents during meals and treatments. Documentation showed lapses in scheduled pest control service visits, and the Maintenance Director was unaware of the extent of the problem.
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.
Surveyors found that several residents with significant medical and cognitive needs did not receive required weekly showers or bathing assistance, as documented in their care plans and facility policy. Documentation was missing or inconsistent, and interviews revealed that some residents had not received showers since admission. The facility did not provide explanations or evidence to account for the missed hygiene care.
Several residents did not receive care and treatment as ordered by physicians and outlined in their care plans, including the application of compression stockings, timely wound care, and provision of an air mattress. Additionally, after an unwitnessed fall, required neurological checks were not completed or documented by staff, despite facility policy and staff acknowledgment of the requirement.
A resident with an indwelling catheter was observed in public areas with their catheter bag uncovered and visible to others on multiple occasions. The resident expressed a preference for privacy, and facility staff confirmed that catheter bags should always be covered in public spaces. These actions failed to uphold the resident's dignity and privacy.
The facility did not adequately promote or facilitate resident self-determination, failing to support resident choice as required. This resulted in residents not being fully supported in making their own decisions regarding their care or daily activities.
Surveyors found that three residents were living in rooms with significant cleanliness and maintenance issues, including dirty walls, heat registers, and curtains, cloudy and dirty windows with cobwebs and dead flies, broken blinds, a detached air/heating unit with exposed dirty piping, and peeling bathroom flooring. Staff acknowledged missed cleaning and maintenance tasks, and there was confusion about responsibilities for certain cleaning duties.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Three residents did not receive necessary pressure ulcer care according to professional standards, including one who developed a facility-acquired DTI that was incorrectly staged and not treated per updated recommendations, and two others who did not have required interventions such as heel floating or timely wound treatments. Staff failed to update care plans and did not consistently document or implement required interventions, leading to deficiencies in pressure injury prevention and management.
A resident did not receive appropriate care and services to maintain or improve their range of motion or mobility, and there was no documented medical reason for the decline.
Three residents with significant fall risks did not consistently receive required fall prevention interventions, including supervision during transfers, fall mats, body pillows, Dycem in wheelchairs, and accessible call lights. Staff left a resident alone in the bathroom despite care plan requirements, and multiple observations showed that fall prevention devices were not in place for two other residents. Staff interviews confirmed knowledge of required interventions, but these were not reliably implemented.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
Two residents received meals that did not match the posted or planned menus, and one resident was served food items listed on their dislike list, despite these preferences being documented. Staff interviews revealed confusion and breakdowns in the process for updating and communicating resident food preferences, resulting in meals not aligning with dietary orders or posted menus.
Staff did not wear gowns as required during a pressure ulcer dressing change for a resident on enhanced barrier precautions, despite clear facility policy and signage. The LPN and CNA performed the procedure without donning gowns, and the DON/Infection Preventionist confirmed this was against expectations for EBP.
The facility did not have a qualified Dietary Manager overseeing food and nutrition services for about a month after the previous manager left. Staff interviews confirmed the absence of a full-time DM during this period, and the Administrator was aware of the vacancy. This affected all residents, as there was no designated individual to direct the food services department.
The facility did not follow the planned menu and failed to notify residents in advance when a listed dessert was not prepared and substituted with mixed fruit. Staff responsible for meal preparation confirmed the substitution was made without prior resident notification, contrary to facility policy and expectations.
Surveyors found that the facility did not maintain kitchen sanitation or proper food storage, with multiple food items lacking labels, open or use-by dates, and improper storage practices. The kitchen also had issues such as ice buildup in the freezer, no temperature logs, employee jackets stored with clean kitchenware, and a dish machine that did not reach the required rinse temperature.
Two residents were found with medications at their bedsides—one with Santyl ointment and another with an Albuterol inhaler—without documented assessments for their ability to safely self-administer these medications. Both residents were cognitively intact, but staff confirmed that required safety assessments had not been completed prior to allowing bedside access.
A resident dependent on hemodialysis did not have consistent documentation of pre- and post-dialysis assessments, and communication between the facility and the dialysis center was lacking. Staff interviews revealed confusion about responsibilities for completing and sending dialysis communication forms, and the resident's binder had not been updated for several months. Leadership confirmed that required documentation and communication had not occurred as expected.
Three residents did not receive their prescribed medications as ordered due to repeated unavailability, delays in pharmacy delivery, and issues with reordering and insurance authorization. Critical medications for conditions such as COPD, depression, and hypercholesterolemia were missed for multiple days, with staff and pharmacy interviews confirming ongoing challenges in medication procurement and contingency supply coverage.
A resident with COPD, pulmonary embolism, and asthma missed multiple doses of critical medications, including a blood thinner and inhalers, due to unavailability and delays in pharmacy delivery. Documentation and staff interviews revealed inconsistent medication reordering processes, lapses in communication, and lack of timely follow-up, resulting in significant medication errors as defined by facility policy. Leadership was unaware of the frequency of missed doses until after the incidents.
The facility failed to document medication and treatment administration for four residents, including those with chronic conditions and fractures. Missing documentation involved medications like insulin and gabapentin, and treatments such as tracheostomy care and wound care. The DON confirmed the missing documentation, emphasizing the expectation for staff to document administered care or reasons for non-administration.
The facility failed to promptly resolve grievances for several residents, as required by their policy. Residents expressed concerns that were not documented or investigated, and the grievance log lacked entries for these issues. The facility's leadership acknowledged the deficiency in handling grievances according to their policy.
The facility failed to conduct thorough investigations into two abuse allegations. In one case, a visitor reported inappropriate behavior by a housekeeper, but the facility did not interview enough residents or document the investigation's results. In another case, a resident reported rough care by a CNA, but the allegation was not promptly reported, and the investigation lacked necessary staff statements. These deficiencies potentially affected all residents.
The facility failed to provide accurate pharmaceutical services, affecting several residents. A resident received incorrect medication orders, leading to adverse effects, while another did not receive prescribed wound care supplies due to supply chain issues. Additionally, a glucose monitor was not labeled, and medications were left unattended, highlighting deficiencies in medication management.
A resident's POA was not notified when occupational and physical therapy were discontinued, despite the facility's policy requiring such notification. The resident, with multiple health conditions, had their POA activated, but there was no documentation of notification when therapies were stopped. The Director of Rehab acknowledged the lack of documentation, and the responsible therapist was no longer at the facility.
A facility failed to immediately report an abuse allegation involving two residents. A CNA reported to an RN that a resident alleged rough handling during care, but the RN dismissed it as the resident's behavior and did not report it to a supervisor or the NHA immediately. The allegation was only reported the next day by Social Services, violating the facility's policy requiring immediate reporting of abuse allegations.
A resident was discharged to an adult living home without a complete discharge summary, lacking vital information such as a medication list and post-discharge care plan. The resident had complex medical needs, including paraplegia and chronic respiratory failure. Facility staff interviews revealed no designated person to ensure discharge instructions were completed, resulting in multiple uncompleted sections in the discharge documentation.
The facility failed to provide appropriate care for two residents, one with congestive heart failure and another with a wound infection. Staff did not apply tubi grips as ordered for a resident with edema, and inaccurately documented their application. Another resident's non-pressure wounds were not assessed for seven days, and the facility lacked proper orders for PICC line care. Coban wraps were not used as ordered due to supply issues, leading to the use of ace bandages instead.
A resident with Traumatic Spinal Cord Dysfunction was left suspended in a Hoyer lift without adequate supervision during a transfer. The assisting RN left the resident to address a phone call, and later, the transfer attempt caused the wheelchair to become unstable. The resident was suspended for six minutes until additional help arrived. The incident highlighted the use of an incorrectly sized sling.
A resident with chronic kidney disease and end-stage renal disease was served a meal not compliant with their prescribed renal/LCS diet, including high-potassium items like french fries and a tomato slice. Interviews revealed gaps in communication and education among dietary staff regarding renal diet restrictions.
A resident with a tracheostomy did not receive the prescribed daily change of their HME trach valve due to a lack of awareness and communication among staff. The LPN was unaware of the HME trach valve, and the facility had never ordered or received the necessary supplies, leading to the resident not receiving the required respiratory care.
A resident in an LTC facility received multiple antibiotics simultaneously for UTI symptoms, despite not meeting the facility's criteria for antibiotic use. The resident was prescribed Rocephin, Bactrim, Macrobid, and Fosfomycin by different medical teams, leading to overlapping treatments. Facility staff acknowledged the issue, noting the resident's insistence on receiving antibiotics and the involvement of multiple medical teams.
A long-term care facility was found to have a medication error rate of 20%, significantly above the acceptable threshold. Errors included administering crushed delayed-release medications, incorrect medication types, and dosages, and failing to notify physicians of deviations from prescribed schedules. These issues were identified during a survey and were not addressed until highlighted by the surveyor.
A resident was administered an incorrect dosage of Carvedilol 69 times due to a failure in the facility's medication order review process. The resident, with a history of hypertension and congestive heart failure, was readmitted with a hospital order for Carvedilol 25 mg, but the facility continued the previous 12.5 mg dosage. The error was not identified until a surveyor's investigation.
A resident on contact isolation for C. diff did not receive proper infection control care due to inadequate hand hygiene practices by staff. An LPN and CNAs failed to wash hands with soap and water between glove changes during trach and incontinence care, contrary to facility policy. The DON confirmed the requirement for soap and water handwashing in such cases.
A resident with severe cognitive impairment was approached by her spouse for sexual relations, but the facility failed to ensure her ability to consent. Despite being informed of the spouse's intentions, no formal assessment was conducted on the day of the incident. The social worker later documented a conversation indicating consent, but this was not recorded at the time, leading to a deficiency finding.
A resident with a history of significant health issues developed a facility-acquired pressure injury on the left heel due to the facility's failure to implement necessary care plan interventions. Despite having a care plan that included offloading the heel and using a heel suspension boot, these measures were not consistently followed. Observations revealed the resident's heel resting directly on the mattress, and the resident reported not being repositioned by staff. Inconsistent documentation of the wound's stage and characteristics further highlighted the deficiency.
The facility failed to prevent foodborne illness by not adhering to proper food handling practices. Cook-K and Dietary Aide-M were observed handling ready-to-eat food with contaminated gloves, failing to wash hands or change gloves after touching non-sanitized surfaces and their nose. The Food Service Director confirmed that all food is served from the same steam table, and staff are expected to use utensils and wash hands, which was not followed.
The facility failed to provide six residents with prior written notice and consent for room changes, as required by policy. These residents were moved without receiving written notification or an explanation for the move, nor were they given the opportunity to choose rooms or meet potential roommates. The facility's rationale for the changes was not communicated in writing, and there was no documentation of consent or follow-up on residents' adjustment to new rooms.
The facility failed to conduct necessary assessments and obtain informed consent before installing bed rails for several residents. This deficiency involved residents with various medical conditions, including cognitive impairments and mobility issues, who had bed rails installed without documented evaluations of safety risks or discussions of risks and benefits. The facility's policy requires these steps, but they were not followed, posing potential safety risks.
The facility failed to report investigation results for two incidents to the State Survey Agency within the required timeframe. One incident involved a resident-to-resident altercation, and the other involved potential misappropriation of funds. Delays were attributed to confusion and misunderstanding of reporting requirements.
A facility failed to incorporate PASARR Level 2 recommendations into the care plan of a resident with developmental disabilities. Despite the resident's need for specialized services, the facility did not develop a comprehensive plan, and the Director of Social Services was unaware of the specific needs or interventions required. Observations revealed missing elements in the resident's room, and no evidence of a reevaluation or plan development was provided.
A facility failed to develop a complete baseline care plan within 48 hours of a resident's admission. The resident, with paraplegia and other conditions, had a physician order for enabler bars to assist with self-positioning, which were not included in the baseline care plan. This omission was confirmed by the Regional Nurse, and the facility did not provide further explanation for the incomplete care plan.
A resident with severe cognitive impairment and sensorineural hearing loss was not provided with necessary hearing aids, despite recommendations from an audiologist. The resident was observed without hearing aids, and staff were unable to locate them, leading to communication difficulties.
A resident with multiple health conditions was not provided with appropriate treatment and services to restore continence. The facility failed to develop a comprehensive care plan for bowel incontinence and did not attempt a toileting program for urinary incontinence. Inconsistent assessments and inadequate documentation contributed to the deficiency.
Failure to Provide Alternate Meal Options and Post Menus
Penalty
Summary
The facility failed to provide alternate meal options of equal nutritional value to residents who declined the main meal, as required by their own policy and regulatory standards. Record reviews, observations, and interviews revealed that three residents out of a sample of eighteen were not regularly offered alternate meals when they did not want the meal originally served. For example, one resident with a moderately impaired cognitive status and on a No Added Salt (NAS) diet was not offered an alternate vegetable when she declined carrots, and she confirmed that no other vegetable options were available. The posted menus only listed alternates for the main entrée, with no alternates for vegetables or starches, and the Always Available Menu was not posted in accessible areas as expected. Observations during meal service confirmed that residents were only offered the main entrée or a single alternate, which was often the same for both lunch and dinner, and no alternate vegetables or starches were provided. The Food Services Manager acknowledged that only one alternate entrée was available per meal and that the Always Available Menu was not posted as required. Residents on special diets were also not provided with alternate meal options. The Registered Dietician stated that her expectation was for alternates of equal nutritive value to be available for each meal and for menus to be posted where residents could access them. Resident interviews further supported these findings, with residents reporting that the alternative menu had been removed about a month prior and that staff did not offer alternatives if residents wanted something other than the main meal. The facility's own policy required that alternatives be immediately available if the primary menu was not to a resident's liking, but this was not being followed. These actions and inactions led to a deficiency in providing resident choice and adequate nutrition as required.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, preparation, and cleanliness. The walk-in freezer had a thick buildup of ice on the floor, walls, and ceiling, with boxes of food also covered in ice. The condition of the freezer was such that the surveyor could not enter due to safety concerns. In the walk-in cooler, an opened bag of lettuce salad was found with a faded, unreadable date and the lettuce appeared brown. Additionally, two fans in the food preparation area had a buildup of a red substance, making them appear dirty and in disrepair, and the exhaust fan above the stove was thick with dust. Dietary staff were observed not following facility policy regarding attire, as two staff members with facial hair were preparing food without beard restraints. Interviews with the Dietary Manager and Nursing Home Administrator confirmed awareness of the freezer's condition and acknowledged the presence of old salad, dirty fans, and lack of beard restraints. The Dietary Manager stated that the freezer had been set too cold after a recent replacement and that the freezer door had not been closing properly, leading to the ice buildup. The manager also indicated that expired or old food items are usually removed daily, but could not provide further explanation for the observed deficiencies.
Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS. The information was required to be based on payroll and other verifiable and auditable data. This deficiency was identified through review of the facility's records and submission practices, which did not meet the required standards for accuracy and completeness as mandated by CMS.
Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Environment
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Despite having a policy that required EBP for residents with wounds or devices such as urinary catheters and feeding tubes, staff did not consistently apply these precautions. Observations revealed that on four of six units, EBP was not implemented, and staff did not use personal protective equipment (PPE) when providing high-contact care activities such as wound care, catheter care, and tube feeding. Multiple residents with wounds, indwelling catheters, or feeding tubes did not have EBP signage or PPE available, and staff were observed providing care without donning gowns or gloves as required by facility policy. Interviews with staff and leadership indicated a lack of understanding and inconsistent application of the EBP policy. The Director of Nursing (DON) and unit managers stated that EBP was only applied to residents with known multidrug-resistant organisms (MDROs) or those in proximity to such residents, contrary to the facility's written policy and CDC guidelines. Staff members, including CNAs, LPNs, and activity aides, demonstrated confusion about when PPE was required and were observed entering rooms and providing care without appropriate infection control measures. Documentation in care plans and Kardexes also failed to instruct staff to use PPE for residents who met EBP criteria. Additionally, the facility did not maintain a sanitary environment in the laundry department. The only sink in the contaminated laundry area was non-functional for one to two weeks, leaving staff without a means to perform hand hygiene after handling soiled laundry and removing PPE. Staff reported using a sink in the employee break room across the hall, which required leaving the contaminated area before performing hand hygiene, in violation of the facility's own laundry policy and standard infection control practices.
Failure to Maintain Effective Pest Control Program for Flies
Penalty
Summary
The facility failed to maintain an effective pest control program to address a significant fly infestation throughout the building. Multiple residents reported ongoing issues with flies in their rooms, common areas, and the dining room. Residents described using personal items such as washcloths and underwear to swat at flies, and some purchased their own fly traps due to the persistent problem. Surveyors directly observed flies in resident rooms, hallways, the dining area, conference room, and kitchen, including flies landing on food and residents during meals and treatments. Staff were also seen using fly swatters in attempts to control the flies. The facility's pest control program required a written agreement with an outside pest service for regular visits, appropriate use of chemicals, and a reporting system for pest issues between scheduled visits. However, record review revealed that the facility did not have pest control service visits for several months, specifically in May, June, and February of one year and July of the previous year. The Maintenance Director was unaware of the fly issue and stated that pest control visits occurred monthly, but this was not supported by documentation. Residents and staff consistently reported the fly problem, with some residents noting that flies landed on their food and bit them, and others stating that the issue was worse near exit doors or in rooms previously occupied by other residents. During the survey, flies were observed in the kitchen, where dietary staff attempted to cover food to prevent contamination. Resident council members also raised concerns about the large number of flies and the cleanliness of the facility. The persistent presence of flies was noted by surveyors throughout the entire survey period, affecting all areas of the facility and all residents present at the time.
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 resident safety and well-being. 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 Provide Required Bathing Assistance to Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and showering, for seven out of eight residents reviewed. Multiple residents, each with significant medical conditions and varying levels of cognitive and physical impairment, did not receive showers at least once a week as required by facility policy and their individual care plans. Documentation was either missing, incomplete, or contained inconsistencies such as signatures from staff who were not present on the documented dates. In several cases, there was no evidence in the electronic medical record (EMR) or shower sheets to confirm that showers were provided, and some residents or their representatives reported not receiving showers since admission. Residents affected included individuals with diagnoses such as cerebral palsy, diabetes, depression, pressure injuries, and severe cognitive impairment. Interviews with residents and their representatives revealed that showers were not provided regularly, and in some cases, not at all. Observations by surveyors noted poor grooming, such as greasy hair, and residents expressed dissatisfaction with their hygiene care. For some residents, care plans indicated the importance of choosing their bathing method, but there was no documentation of these preferences being honored or of alternative hygiene measures being provided when showers were missed. The facility's own policies required that residents be offered showers at least weekly, either as requested or per the facility schedule, and that assistance be provided according to each resident's care plan. Despite this, there was a lack of consistent documentation and follow-through. In some instances, care plans were outdated or lacked specific instructions for staff, and there was no evidence of staff attempts to address refusals or barriers to bathing. The surveyors shared these concerns with facility leadership, but no explanations or additional documentation were provided to account for the missed showers or to demonstrate that residents' hygiene needs were being met as required.
Failure to Provide Care and Treatment According to Physician Orders and Facility Policy
Penalty
Summary
Multiple residents did not receive care and treatment in accordance with physician orders, care plans, and facility policies. Several residents with physician orders for compression stockings were repeatedly observed not wearing them, despite documentation in their care plans and treatment administration records indicating they should be applied daily. There was no documentation in the medical records to explain the absence of the stockings, and staff confirmed that the expectation was for the stockings to be applied or refusals to be documented. Residents themselves confirmed that staff had not been applying the stockings as ordered. One resident with a vascular/venous stasis ulcer did not receive a prescribed treatment on a specific date, and there was a delay in providing an ordered air mattress. The resident reported having to request the air mattress multiple times and experienced discomfort due to the delay. Documentation confirmed the air mattress was not provided until several days after the physician order, and the wound treatment was not completed as scheduled, with staff citing workload as a reason for the missed care. Another resident experienced an unwitnessed fall, and the facility failed to complete and document neurological checks as required by facility policy for unwitnessed falls. The fall packet and checklist were incomplete, and staff interviews confirmed that neuro checks should have been performed and documented but were not. The DON and other staff acknowledged the lack of documentation and completion of required post-fall assessments.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
A resident with a diagnosis of neurogenic bladder and an indwelling urinary catheter was observed on multiple occasions in common areas of the facility with their catheter bag uncovered and visible to other residents, staff, and visitors. The resident's comprehensive care plan documented the presence of the indwelling catheter, and the expectation was for the catheter bag to be covered with a privacy bag at all times when in public areas. On two separate occasions, surveyors observed certified nursing assistants transporting and placing the resident in communal spaces with the catheter bag exposed and not covered by a privacy bag, making the contents visible to others. When interviewed, the resident expressed a preference for the catheter bag to be covered, questioning why others should see its contents. The unit manager confirmed that the facility's expectation is for catheter bags to always be covered in privacy bags when residents are in public areas. The deficiency was identified based on these observations and interviews, which demonstrated a failure to ensure the resident's dignity and privacy as required.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulation.
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for three residents. In one case, a resident's room had a wall and heat register coated with dirt and a thick layer of dust, and the curtains hanging over the heat register were also dirty and had black spots. Another resident's room had windows with a thick white film on the inside, making them appear cloudy, and the outside of the windows was dirty. There was also a cobweb with two dead flies near the window, and the window blinds were broken and not functional. In a third instance, a resident's air conditioning and heating unit was observed to be disconnected and coming off the wall on one side, with an exposed metal pipe covered in dirt and cobwebs. The shared bathroom flooring in this room was peeling off the wall, exposing dirt and the drywall behind it. The resident reported that the air/heating unit was ancient, loud, and posed a risk of injury due to its position. The maintenance director confirmed that there was no scheduled work for this room and had not inspected it since the resident moved in. Housekeeping staff described daily and monthly deep cleaning routines, including cleaning windows and sills, but acknowledged that the inside sills and windows in one resident's room had been missed during the last deep clean. The broken blind in the same room prevented proper cleaning, and there was confusion among staff regarding responsibility for cleaning the outside windows. Facility staff acknowledged the concerns when they were brought to their attention by surveyors.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Appropriate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries for three of five residents reviewed. One resident developed a facility-acquired suspected deep tissue injury (DTI) that was incorrectly staged after it progressed to include slough, and the recommended change in wound treatment was not implemented in a timely manner. The care plan was not updated to reflect changes in the wound, and staff continued to use the previous treatment despite new recommendations. Additionally, multiple observations showed that the resident’s heels were not floated as required by the care plan, and staff interviews revealed a lack of awareness regarding this intervention. Another resident, who was at risk for pressure injuries and had a history of heel ulcers, was observed with heels resting directly on the bed and not being floated, contrary to the care plan. Documentation of turning and repositioning was incomplete, with several shifts indicating that the resident was not repositioned as required. Staff interviews further indicated uncertainty about the interventions in place for pressure injury prevention. A third resident did not consistently receive pressure injury treatments as ordered during the review period. The facility’s own policy required regular assessment, accurate staging, and timely updates to care plans and interventions based on wound changes, but these standards were not met. Documentation and communication lapses, incorrect wound staging, and failure to implement or update care interventions contributed to the deficiencies identified by surveyors.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent a decline in the resident's ROM or mobility, except in cases where such decline was due to a documented medical reason. This resulted in the resident not receiving necessary interventions to maintain or improve their physical function.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and assistance devices to prevent accidents, as required by their individualized care plans and the facility's fall prevention policy. For one resident with hemiplegia and a history of falls, staff transferred the resident to the toilet and left them alone in the bathroom, resulting in an unwitnessed fall. Multiple staff interviews confirmed that the resident should not have been left unattended due to their need for assistance with transfers, and the care plan was not updated with new interventions following the incident. Documentation and interviews revealed that staff were aware of the resident's tendency to self-transfer, yet no additional measures were implemented to address this ongoing risk. For a second resident with severe cognitive impairment and high fall risk, surveyor observations repeatedly found that required fall interventions, such as a fall mat beside the bed and the call light within reach, were not consistently in place. On several occasions, the fall mat was folded against the wall or missing, and the call light was either out of reach or behind the resident's pillow. Nursing staff did not ensure these interventions were implemented, even after providing care in the resident's room. The resident's care plan and care card specified these interventions, but they were not reliably followed during the survey period. A third resident, also with severe cognitive impairment and high fall risk, was observed multiple times without key fall prevention interventions in place. These included the absence of a fall mat, body pillows, Dycem in the wheelchair, and the call light within reach, despite these being listed in the resident's care plan and care card. The resident's bed was not consistently kept in the low position as required, and personal items were not always within reach. Staff interviews indicated reliance on care cards for intervention information, but surveyor observations demonstrated that interventions were not consistently implemented for this resident.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Follow Posted Menus and Resident Food Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and served as posted for two residents, resulting in meals that did not match the planned or posted menus and resident preferences. For one resident, multiple meal trays did not correspond with the posted or planned menus, with specific items such as cold cereal and Cream of Wheat missing from breakfast trays, and mixed vegetables substituted for listed menu items like Brussels sprouts and butternut squash at lunch. The resident reported that the facility did not inform them of menu changes, and observations confirmed discrepancies between the posted menus, planned menus, and what was actually served. Another resident, who was cognitively intact and had documented food dislikes, received meals that included items from their dislike list, such as white bread, despite these preferences being clearly noted on the meal tray ticket. This resident also did not receive all items listed on their meal ticket, such as yogurt, and their trays did not match the posted or planned menus on several occasions. Interviews with staff revealed a lack of clarity and breakdown in the process for updating and communicating resident food preferences, with the interim Dietary Manager stating that no new preference slips had been received and the front desk receptionist unaware of receiving any slips from nursing. The facility's policy required that menus be planned in advance, served as written unless substitutions were necessary, and posted in relevant areas. However, observations and interviews demonstrated that these procedures were not consistently followed, leading to residents receiving meals that did not align with their dietary orders, posted menus, or personal preferences. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records and policies.
Failure to Use Required PPE During Pressure Ulcer Dressing Change
Penalty
Summary
Staff failed to don the appropriate personal protective equipment (PPE) during a pressure ulcer dressing change for one resident who was under enhanced barrier precautions (EBP). Specifically, during an observed dressing change to a stage 4 pressure ulcer, neither the LPN nor the CNA wore a gown, despite facility policy and signage indicating that both gloves and gowns were required for high-contact care activities under EBP. The PPE bin and signage were present outside the resident's room, clearly stating the need for gown and glove use, but these were not followed during the procedure. The resident involved had a history of paraplegia, a stage 4 pressure ulcer, above the knee amputation, and heart failure, and was cognitively intact according to the most recent assessment. Physician orders required regular dressing changes to the ischium wound. The Director of Nursing/Infection Preventionist confirmed that the expectation was for staff to wear gowns during dressing changes for residents on EBP, which was not adhered to in this instance.
Failure to Maintain Qualified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that a qualified Dietary Manager (DM) was designated to act as the director of food and nutrition services when the DM position became vacant. According to the job description, the DM is responsible for assisting the Dietitian in planning, organizing, developing, and directing the overall operation of the Food Services Department in accordance with regulatory standards. The former DM ended employment on 04/02/25, and there was no replacement or acting DM for approximately one month. Multiple staff interviews confirmed that there was no full-time DM overseeing the kitchen during this period. Dietary aides and cooks reported the absence of a DM, and the Administrator acknowledged awareness of the vacancy, stating that a contracted company only recently took over management of the kitchen. This lapse had the potential to affect all 89 residents in the facility, as there was no qualified individual overseeing food and nutrition services during the vacancy.
Failure to Follow Menus and Notify Residents of Food Substitutions
Penalty
Summary
The facility failed to ensure that menus and menu extensions were followed as required, including providing appropriate, approved food substitutions and adhering to recipes for all 89 residents. During a tray line observation, kitchen staff served mixed fruit instead of the bread pudding listed on the menu, as the bread pudding had not been prepared the night before due to time constraints. Staff responsible for preparing the bread pudding confirmed it was not made and indicated that residents were not notified in advance of the substitution. The Dietary Manager stated that residents should be notified of any menu changes in advance, and the Administrator confirmed that residents needed to be alerted if there were changes to the menu. Review of facility policy and the weekly menu confirmed that the planned meal was not served as specified.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, as evidenced by improper labeling, dating, and storage of food items. During an inspection, surveyors observed a container of rice labeled with an expiration date, but a container of sugar was found without any label or date, and a plastic cup was in direct contact with the sugar. In the walk-in freezer, there was a partial sheet of ice, iced condensation on the ceiling, and frost on several boxes, with no temperature logs available for the month. The walk-in refrigerator contained multiple food items, such as fruit cocktail, yogurt, parmesan cheese, slaw, breaded chicken breasts, and an unknown product, many of which lacked open or use-by dates or labels. Seven bags of an unknown yellow product were also found without labels or dates. Behind the stove, disposable plates with slices of pie were left for approximately one month. Employee jackets were stored on racks with clean kitchenware, and the dish machine failed to reach the required rinse temperature, with no temperature logs maintained. The Dietary Manager confirmed several of these issues, acknowledging the lack of proper labeling, dating, and storage as potential infection control problems. The Dietary Manager was also unaware of a cleaning schedule for the kitchen. The Administrator, who had been in the position for three weeks, was aware that the kitchen required attention regarding sanitation. These findings indicate multiple failures to follow facility policies and FDA Food Code guidelines for food storage and kitchen sanitation.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for their ability to safely self-administer medications that were observed at their bedsides. One resident, admitted with a left ischium wound and determined to be cognitively intact, had a tube of Santyl ointment at the bedside and reported applying it as needed. Review of the resident's medical record showed no evidence of an assessment for safe self-administration of the medication. An LPN confirmed the medication was left at the bedside and was unaware of any assessment having been completed. Another resident, also cognitively intact and admitted with shortness of breath, was found with an Albuterol inhaler at the bedside. The resident stated she had been assessed for safe use of the inhaler, but review of the medical record did not show any such assessment, nor was there a physician order for the inhaler. The ADON confirmed that no safety assessment had been completed for this resident regarding self-administration of the inhaler, despite the resident having access to it for the past month.
Failure to Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding dialysis care for a resident dependent on hemodialysis. Review of the resident's records showed that pre- and post-dialysis assessments, including vital signs and weights, were not consistently documented as required by facility policy and physician orders. The care plan for the resident did not address communication between the dialysis center and the facility, and there was a lack of completed dialysis communication forms in the resident's binder since October of the previous year. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for preparing and sending the dialysis communication forms. Some staff members stated they completed the forms and sent them with the resident, while others denied involvement or were unsure of the process. The resident reported that vital signs were not always checked before and after dialysis and that the dialysis binder had not been updated or used by staff for several months. Further interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the expectation was for staff to use the communication forms and document pre- and post-dialysis assessments. However, they acknowledged that no completed forms had been located for the resident since October, and that staff often relied on the dialysis center to monitor vital signs and weights. This lack of documentation and communication had the potential to affect the health of residents receiving dialysis.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for three of four residents reviewed for medication availability. Multiple instances were documented where residents did not receive their prescribed medications due to unavailability, delays in pharmacy delivery, or issues with reordering and insurance authorization. For example, one resident with chronic conditions such as COPD, heart failure, and depression missed several doses of critical medications including blood thinners, antidepressants, antibiotics, steroids, and inhalers. Documentation in the electronic medical record and medication administration records showed repeated notations of medications being unavailable, on order, or pending delivery, with some medications not being delivered for multiple days. The resident confirmed missing important medications and staff interviews revealed challenges with the pharmacy's delivery system, insurance limitations, and the facility's reordering process. Another resident with mood disorder and depression did not receive a prescribed antidepressant because it was not available at the time of administration. The LPN responsible for medication administration noted the medication was on order and not delivered, and the pharmacy confirmed that while the medication was filled, it was not yet sent out. The facility's contingency supply was supposed to cover such gaps, but staff reported that it did not contain many needed medications. The DON and ADON acknowledged ongoing issues with medication availability, difficulties with the pharmacy's ordering system, and the need for frequent follow-up with the pharmacy to track and obtain medications. A third resident with hypercholesterolemia experienced multiple missed doses of a cholesterol-lowering medication due to unavailability and delays in pharmacy delivery. The MAR and clinical documentation indicated several days where the medication was not administered because it was either unavailable or waiting on delivery. The pharmacy records showed that insurance limitations sometimes restricted the amount dispensed, resulting in the need for more frequent reorders. Staff interviews confirmed that the resident often ran out of medication and experienced delays, and the contingency supply did not include the needed medication. The DON provided evidence of some training on medication availability but acknowledged that documentation was not specific enough to address the delays experienced by this resident.
Failure to Ensure Resident Free from Significant Medication Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as required by policy and physician orders. The resident, who had a history of chronic obstructive pulmonary disease (COPD), pulmonary embolism, and asthma, experienced multiple missed doses of critical medications, including a blood thinner (rivaroxaban), inhalers (umeclidinium bromide), roflumilast, and Dupixent injections. Documentation in the electronic medical record (EMR) and medication administration records (MARs) showed repeated instances where these medications were not available or not administered as ordered, with nursing staff noting the unavailability and pending pharmacy deliveries over several days. Interviews with staff and pharmacy personnel revealed that medication reordering processes were inconsistent, with reliance on fax or phone requests and a contingency supply (Pyxis) that did not contain the needed medications. The pharmacy indicated that some medications were sent according to insurance limitations, but there were lapses in communication and follow-through, resulting in missed doses. Nursing staff reported delays in medication delivery, even for STAT orders, and acknowledged that medications were sometimes not reordered in a timely manner or did not arrive as expected. The resident reported missing important medications for COPD and blood thinners, though he did not experience respiratory concerns or blood clots during the period in question. The physician and pharmacy both considered the missed doses of blood thinners and COPD medications to be significant medication errors. Facility leadership, including the DON and ADON, were not fully aware of the extent or frequency of the missed medications until after the fact, and expected staff to follow procedures for obtaining and administering critical medications.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure proper documentation of care and services for four residents, leading to a deficiency in maintaining accurate medical records. The facility's policy requires that each resident's medical record accurately reflects their experiences and includes timely documentation. However, the review revealed that medications and treatments were not documented as administered per physician orders for residents with various medical conditions, including chronic respiratory failure, diabetes mellitus, hypertension, fractures, and quadriplegia. For one resident, multiple medications and treatments, such as beta blockers, hypertension medication, tracheostomy care, and heel checks, were not documented as administered. Another resident with a fractured tibia and diabetes mellitus had missing documentation for medications like insulin and gabapentin, as well as treatments for knee care and wound care. Similarly, a resident with a shoulder fracture and schizophrenia had missing documentation for treatments to the buttocks and ileostomy care. Lastly, a resident with quadriplegia and pressure ulcers had missing documentation for wound care and ostomy bag maintenance. The Director of Nursing confirmed the missing documentation during an interview and stated that the expectation is for staff to document when medications and treatments are administered. If unable to perform the tasks, staff are expected to document the reason. The lack of documentation does not ensure that treatments or medications were completed, potentially causing delays in care.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for five residents, as required by their grievance policy. On multiple occasions, residents R11, R15, and R16 expressed concerns during interviews, but there was no documentation of these grievances being investigated or resolved. The facility's grievance log did not contain any entries for these residents, indicating a lack of follow-through on the grievance process. This oversight was confirmed by the social worker and acknowledged by the nursing home administrator, director of nursing, and director of operations. Resident R7 also had multiple complaints documented in progress notes, but there was no evidence that these concerns were investigated or addressed. The director of nursing expected that any concerns raised by residents would be investigated by the nursing staff and reported to her, but this did not occur in R7's case. The nursing home administrator admitted to having verbal communication with R7 about the concerns but did not complete a formal grievance process. Additionally, a grievance filed by R3's representative was inadequately handled. The grievance log indicated a resolution, but there was no detailed investigation or documentation of the grievance's confirmation or the date a written decision was provided. The facility's leadership acknowledged the lack of a thorough investigation and documentation, further highlighting the deficiency in handling grievances according to their policy.
Incomplete Investigations into Abuse Allegations
Penalty
Summary
The facility failed to ensure a thorough investigation into allegations of abuse involving two separate incidents. In the first case, a visitor alleged that a housekeeper engaged in sexually inappropriate behavior. Although the housekeeper was suspended and the police were notified, the facility's investigation was incomplete. Only 7 out of 73 residents were interviewed, and there was no documentation summarizing the investigation's results. The facility did not determine if other residents had similar experiences with the housekeeper, who had been employed since 2022. In the second incident, a resident, identified as R10, reported rough care by a CNA to a registered nurse. The allegation was not immediately reported to a supervisor, and the investigation was insufficient. The facility's documentation lacked statements from the registered nurse and other staff members who worked the same shift. Additionally, the resident statements collected were from individuals residing on different units, not those under the care of the accused CNA. These deficiencies had the potential to affect all 73 residents in the facility. The facility's policies required immediate and thorough investigations of abuse allegations, including interviewing all involved parties and ensuring resident protection. However, the facility did not adhere to these policies, resulting in incomplete investigations and a lack of documentation to support the actions taken.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide accurate pharmaceutical services, affecting several residents. One resident, R3, was readmitted with a diagnosis of C. Diff and had a medication order for Bisacodyl suppository transcribed incorrectly. Instead of being administered as needed, it was scheduled every 24 hours, leading to episodes of loose stools. The error was identified by the resident's daughter, who is the POA, and was brought to the attention of the Director of Nursing. The order was eventually corrected, but not before the resident experienced adverse effects. Another resident, R7, did not receive the ordered Coban wraps for wound care as prescribed. The facility lacked the necessary supplies, leading to the use of alternative materials like Ace wraps, which were not in accordance with the physician's orders. This resulted in the resident experiencing pain and discomfort, and at one point, the resident had to order their own supplies. The facility's supply chain issues and lack of proper documentation for order requests contributed to this deficiency. Additionally, the facility failed to ensure the proper labeling and security of medical equipment and medications. R17's glucose monitor was not labeled, leading to confusion about its ownership. Furthermore, medications were left unattended on top of the medication cart, posing a risk to residents and staff. These lapses in protocol highlight significant deficiencies in the facility's pharmaceutical services and medication management practices.
Failure to Notify POA of Therapy Discontinuation
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) when there was a need to alter treatment, specifically when occupational therapy (OT) and physical therapy (PT) were discontinued. The resident, who had been diagnosed with congestive heart failure, diabetes mellitus, and end-stage renal disease, had their POA activated in July 2023. Despite the facility's policy requiring notification of changes to the resident's representative, the POA was not informed when OT was discontinued on June 26, 2024, and PT on July 2, 2024. The surveyor reviewed the resident's medical records and found no documentation indicating that the POA had been notified of these changes. During an interview with the Director of Rehab/Certified Occupational Therapy Assistant (DOR/COTA), it was revealed that the resident had been on and off therapy, with OT and speech therapy being resumed after a hospitalization and readmission. The DOR/COTA acknowledged that while therapists or the Director of Therapy are supposed to notify the POA, there was no documentation to confirm this had occurred for the discontinuation of OT and PT. The discharge summaries provided did not include any notes about notifying the POA, and the occupational therapist responsible for the discharge was no longer employed at the facility. The Nursing Home Administrator was informed of these findings, but no explanation was provided for the lack of notification to the POA.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents, R10 and R8, as required by their policy. On 5/16/24, a CNA reported to an RN that R10 alleged the CNA was rough during care. The RN dismissed the allegation as R10's behavior and did not report it to a supervisor or the Nursing Home Administrator (NHA) immediately. The allegation was only brought to the attention of the NHA on 5/17/24 by Social Services, which was a violation of the facility's policy that mandates immediate reporting of such allegations. R10, who was cognitively intact and dependent on staff for most activities of daily living, reported the rough handling. The facility's policy requires that any suspicion or report of abuse be investigated immediately and reported to the appropriate authorities within two hours if it involves abuse or results in bodily injury. The delay in reporting and addressing the allegation of abuse indicates a failure to adhere to these protocols, potentially compromising the safety and well-being of the residents involved.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident, identified as R10, who was discharged to an adult living home. The discharge summary was incomplete, lacking essential information such as a list of medications, a final summary of the resident's status, and a post-discharge plan of care. This deficiency was identified during a surveyor's review of R10's records, which revealed that there was no discharge order or documentation of the steps taken to coordinate a successful discharge. R10 had multiple medical conditions, including paraplegia, morbid obesity, chronic respiratory failure, and depression, among others. The resident's care plan included various focused problems such as ADL deficits, potential for dehydration, risk of falls, and mood impairment. Despite these complex needs, the discharge instructions were incomplete, missing critical sections like respiratory and skin evaluations, diet recommendations, and a reconciled medication list. Interviews with facility staff, including social workers and nursing staff, indicated a lack of a designated person responsible for ensuring the completion of discharge instructions. The surveyor noted that the discharge instructions contained multiple uncompleted sections, and there was no documentation in the electronic medical record of R10's discharge. The facility's failure to provide a comprehensive discharge summary and coordinate care effectively was highlighted as a significant deficiency.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, R3 and R7. For R3, who has diagnoses including congestive heart failure, diabetes mellitus, and end-stage renal disease, the facility staff did not apply tubi grips to the resident's bilateral lower extremities as ordered by the physician. Despite the care plan and physician orders specifying the use of tubi grips for edema management, observations on two consecutive days revealed that the staff did not apply them, and the treatment administration record inaccurately indicated that the tubi grips had been applied. For R7, who was admitted for intravenous antibiotics due to a wound infection, the facility failed to comprehensively assess non-pressure wounds for seven days and did not have proper orders for the care of the resident's PICC line. The facility staff used ace bandages instead of Coban wraps as ordered by the physician, and there were no documented orders for flushing the PICC line with heparin or changing the PICC dressing. The facility also experienced a shortage of Coban, leading to the use of alternative materials, and the resident had to order their own supplies for wound care. The deficiencies in care for both residents highlight a lack of adherence to physician orders and professional standards of practice. The facility's failure to ensure the availability of necessary medical supplies and to accurately document and follow treatment protocols contributed to the inadequate care provided to the residents.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate assistance and supervision during the transfer of a resident, identified as R5, using a Hoyer lift. R5, who has a primary medical condition of Traumatic Spinal Cord Dysfunction and functional limitations in both upper and lower extremities, requires the assistance of two staff members for transfers. During an observed transfer, RN-L, who was assisting Hospice RN-CC with the transfer, left R5 suspended in the air to address a ringing phone in the hallway. This action left R5 in a potentially unsafe situation as the resident was suspended in the sling without adequate supervision. Further complications arose when RN-L and Hospice RN-CC attempted to lower R5 into the wheelchair, causing the front wheels of the wheelchair to lift off the ground. RN-L expressed concern about the potential for R5 to fall and left the room to seek additional help, leaving R5 suspended for approximately six minutes. During this time, Hospice RN-CC noted that R5 had been using an incorrectly sized sling, which was too small, and had brought an XL sling for the transfer. The deficiency was reported to the Nursing Home Administrator (NHA) by the surveyor.
Inappropriate Meal Served to Resident on Renal Diet
Penalty
Summary
The facility failed to provide a resident, identified as R3, with the appropriate food items for a renal/LCS (low concentrated sweets) diet as prescribed by the physician. R3, who has chronic kidney disease with heart failure and end-stage renal disease, was observed receiving a meal that included french fries and a tomato slice, both of which are high in potassium and not suitable for a renal diet. The physician's orders for R3 specified a Renal, LCS diet with regular texture and thin fluid consistency, yet the meal served did not comply with these dietary restrictions. Interviews with the Registered Dietitian (RD) and Food Service Director (FSD) revealed a lack of proper communication and education regarding the dietary needs of residents on a renal diet. The RD acknowledged the need for further education in the kitchen, especially with new cooks, and the FSD mentioned a book in the kitchen listing restricted foods, which was not effectively utilized. The surveyor's findings were communicated to the Nursing Home Administrator, but no explanation was provided for the dietary oversight.
Failure to Provide Prescribed Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident with a tracheostomy, as they did not change the resident's HME (heat moisture exchanger) trach valve daily according to physician orders. The resident, who was admitted with diagnoses including chronic respiratory failure, morbid obesity, and paralysis of vocal cords and larynx, had a physician order dated 5/17/24 for the daily change of the HME trach valve. Despite this order, the surveyor observed that the licensed staff were checking and initialing the medication administration record (MAR) indicating the HME trach valve was being changed daily, but the actual change was not performed. During the survey, it was revealed that the LPN responsible for the resident's care was unaware of what an HME trach valve was and could not locate it in the facility. The Medical Records/Central Supply staff also confirmed that the HME trach valves had never been ordered or received in the building. The Director of Nursing acknowledged that the necessary supplies were not ordered and that there was a lack of communication among the nursing staff regarding the HME trach valve. This oversight resulted in the resident not receiving the prescribed respiratory care as per the physician's orders.
Resident Received Unnecessary Multiple Antibiotics for UTI
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, leading to the administration of multiple antibiotics simultaneously. The resident, who was cognitively intact and dependent on staff for personal hygiene and transfers, began experiencing symptoms of a urinary tract infection (UTI) and was subsequently prescribed multiple antibiotics by different medical teams. Despite the facility's policy on antibiotic stewardship, the resident received Rocephin, Bactrim, Macrobid, and Fosfomycin over a short period, without meeting the McGeer's criteria for initiating antibiotic treatment. The resident's symptoms began with burning, itching, and pain during urination, prompting a urinalysis and culture test. However, the resident was prescribed Rocephin and Bactrim before the culture results were available, and later Macrobid was added based on the culture results. The facility's documentation indicated that the resident did not meet the McGeer's criteria for starting antibiotics, yet the resident was on three different antibiotics simultaneously. The facility's staff, including the Director of Nursing and Unit Manager, acknowledged the involvement of multiple medical teams in prescribing the antibiotics, which contributed to the overlapping treatments. Interviews with facility staff revealed that it was not standard practice to administer multiple antibiotics for a UTI, and concerns were raised about the potential harm of such practices. The facility's Director of Nursing and other staff members recognized the issue but noted that the resident insisted on receiving the antibiotics. The facility's failure to adhere to its antibiotic stewardship program and the lack of communication between medical teams led to the unnecessary administration of multiple antibiotics, which was not in line with the facility's infection control protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate reaching 20%. This deficiency was identified through multiple instances of improper medication administration. One resident received crushed Depakote, a delayed-release medication that should not be crushed, along with other scheduled medications at a time significantly later than prescribed. Another resident received their scheduled medications, Gabapentin and Tramadol, outside the prescribed time frame without proper documentation or notification to the physician. Additionally, a third resident did not receive the correct medication as per physician orders. The resident was supposed to receive Complex B-100 extended release with biotin and folic acid but was instead given a different B complex with B12. Furthermore, the resident received an incorrect dosage of Carvedilol due to a failure to update the medication list following a hospital discharge summary. These errors were not identified or corrected until brought to the facility's attention by the surveyor. The facility's policy requires medications to be administered within a specific time frame and mandates physician notification if this is not possible. However, these protocols were not followed, as evidenced by the lack of documentation and physician notification for the medication errors observed. The Director of Nursing and Unit Manager acknowledged the discrepancies and the failure to adhere to the established medication administration schedule, which contributed to the high medication error rate.
Medication Error in Carvedilol Dosage for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Carvedilol. The resident, who was readmitted to the facility, had a discharge order from the hospital to receive Carvedilol 25 mg every 12 hours. However, the facility continued administering the previous dosage of 12.5 mg, resulting in the resident receiving the incorrect dosage 69 times over a period from August to September. The deficiency occurred due to a failure in the facility's process for reviewing and transcribing medication orders upon the resident's readmission. The Unit Manager and floor nurse were responsible for reviewing hospital records and verifying medication orders, but the change in Carvedilol dosage was not identified or corrected. The Director of Nursing later acknowledged the error and noted that the medication error variance was documented only after the surveyor's inquiry. The resident involved had a medical history that included bilateral lower extremity edema, hypertension, and congestive heart failure. At the time of readmission, the resident was stable and alert, with no respiratory distress. Despite the hospital's clear discharge instructions, the facility's oversight led to the continued administration of an incorrect medication dosage, which was not addressed until the surveyor's investigation.
Inadequate Hand Hygiene Practices for Resident on C. diff Isolation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of hand hygiene, for a resident on contact isolation due to Clostridioides difficile (C. diff) infection. During tracheostomy and incontinence care, the LPN did not perform hand hygiene after removing gloves and before donning new ones, despite the facility's policy requiring hand washing with soap and water in such situations. The LPN was observed performing trach care and suctioning without washing hands between glove changes, which is a critical step in preventing the spread of infection. Additionally, CNAs providing incontinence care to the same resident also failed to adhere to proper hand hygiene protocols. After removing gloves, one CNA used hand sanitizer instead of washing hands with soap and water, as required for residents on contact isolation for C. diff. The Director of Nursing confirmed that the correct procedure should involve washing hands with soap and water. These lapses in following established hand hygiene protocols contributed to the deficiency in the facility's infection prevention and control program.
Failure to Ensure Resident's Consent for Sexual Relations
Penalty
Summary
The facility failed to provide medically related social services to assist a resident, identified as R1, in consenting to sexual relations, leading to a deficiency. R1, who was admitted with multiple diagnoses including severe cognitive impairment, was approached by her spouse for sexual relations while residing at the facility. Despite being informed of the spouse's intentions, the facility did not take steps to ensure R1's ability to consent on the day of the incident. R1's medical records indicated severe cognitive impairment, with a BIMS score of 00, and documented behaviors such as hallucinations and delusions. On the day of the incident, the social worker claimed to have spoken with R1 but did not complete a formal assessment of R1's mental status and ability to consent. The nursing notes from that day documented R1 as being alert and oriented x2, which was inconsistent with her baseline confusion documented in previous fall risk evaluations. The social worker later made a late entry in the medical record, stating that R1 expressed a desire for sexual relations with her husband, but this was not documented at the time of the incident. The surveyor noted the lack of documentation and formal assessment regarding R1's ability to consent to sexual relations. Despite the social worker's verbal account of R1's consent, there was no formal documentation or assessment to support this claim. The facility's failure to ensure R1's ability to consent to sexual relations and the lack of appropriate documentation led to the deficiency finding.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure that a resident with pressure injuries received necessary treatment and services consistent with professional standards of practice. The resident, who had a history of paraplegia, chronic obstructive pulmonary disease, and other significant health issues, developed a facility-acquired suspected deep tissue injury (SDTI) on the left heel. Despite having a care plan that included interventions such as offloading the heel and using a heel suspension boot, these measures were not consistently implemented, as observed by the surveyor. The resident's care plan included specific interventions to prevent and treat pressure injuries, such as floating the heels while in bed and using a soft boot. However, during multiple observations, the surveyor noted that the resident's left heel was resting directly on the mattress without offloading, contrary to the care plan and facility policy. The resident reported that staff did not offer to turn and reposition him, and he was unable to do so independently due to his condition. The surveyor also noted inconsistencies in the documentation of the wound's staging and characteristics, which further indicated a lack of adherence to the care plan. The facility's documentation and assessments were inconsistent, with varying descriptions of the wound's stage and characteristics. The facility initially did not provide evidence that the pressure injury was unavoidable, and the surveyor observed multiple instances where care plan interventions were not implemented. Despite the facility's later claim that the injury was unavoidable, the surveyor found no supporting documentation from a physician to substantiate this claim. The lack of consistent implementation of the care plan and inadequate documentation contributed to the deficiency identified by the surveyor.
Deficiency in Food Handling Practices
Penalty
Summary
The facility failed to distribute and serve food in a manner that prevents foodborne illness to 74 out of 74 residents who receive their meals from the main serving kitchen. Observations revealed that Cook-K, while wearing gloves, repeatedly touched non-sanitized food surfaces such as metal food carts and plate lids, and then handled ready-to-eat food without changing gloves or washing hands. This occurred multiple times within a short period, indicating a consistent failure to adhere to proper food handling practices as outlined in the facility's policy. Additionally, Dietary Aide-M was observed transferring yogurt from a large container to individual service containers while wearing gloves. During this process, Dietary Aide-M was seen wiping their nose with gloved hands and continuing to handle the food without changing gloves or washing hands. This action further exemplifies the lack of adherence to the facility's food safety policies, which require proper handwashing and glove use to prevent cross-contamination. The Food Service Director-N confirmed that all food served to residents comes from the observed steam table and acknowledged that staff are expected to use utensils and wash hands when handling ready-to-eat food. Despite this expectation, the observed practices of Cook-K and Dietary Aide-M did not align with these standards, resulting in a deficiency in food safety practices at the facility.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide prior written notice to six residents regarding room changes, as required by their policy. These residents, identified as R2, R12, R33, R35, R39, and R46, were transferred to different rooms without receiving written notification or an explanation for the move. Additionally, they were not given the opportunity to choose from a selection of rooms or meet potential new roommates before the transfer. The facility's policy mandates that residents and their representatives be informed in advance of room changes, including the reasons for such changes, in a language and manner they understand. Interviews and record reviews revealed that the facility did not document consent from the residents or their representatives for the room transfers. For instance, R2 and R35 reported to the surveyor that they were moved without permission or prior knowledge, and their electronic medical records (EMR) lacked documentation of advance written notification or consent. Similarly, R12, R33, R39, and R46's EMRs also showed no evidence of written notice or consent for their room changes. The facility's social services director admitted that verbal consent was obtained but not documented in the residents' progress notes. The facility's rationale for the room changes was to relocate more independent residents to the front of the facility for aesthetic reasons and to move dependent residents to the back. However, this decision was not communicated in writing to the affected residents or their representatives, as required by the facility's policy. The surveyor noted that there was no follow-up documentation to assess how the residents were adjusting to their new rooms, further highlighting the lack of compliance with the facility's procedures.
Deficiency in Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to adhere to its policy regarding the use of bed rails, resulting in deficiencies related to the lack of assessments, informed consent, and documentation for several residents. The facility's policy mandates a comprehensive assessment of residents before the installation of bed rails, including evaluating alternatives and assessing risks. However, the facility did not provide evidence of such assessments or informed consent for seven residents who were reviewed for repositioning bars. These residents had bed rails installed without documented assessments of their safety risks or discussions of the risks and benefits with them or their representatives. For instance, one resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy and diabetes, had quarter side rails installed without a prior assessment or consent. Another resident, who is cognitively intact but has quadriplegia, had half side rails installed without the necessary documentation. Similarly, a resident with cerebral infarction and hemiplegia had enabler bars installed without an assessment or consent. These omissions were consistent across all seven residents reviewed, indicating a systemic issue in the facility's adherence to its policy. The surveyor's observations and interviews revealed that the facility did not attempt appropriate alternatives before resorting to bed rails, nor did it maintain adequate records of assessments and consents. The lack of documentation and failure to follow the facility's policy on bed rail use posed potential safety risks to the residents, as the necessary evaluations and informed consents were not obtained prior to the installation of these devices.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of investigations for two incidents to the State Survey Agency within the required 5 working days. In the first incident, a resident with severe cognitive impairment and a history of hallucinations and delusions was involved in a resident-to-resident altercation during a scheduled activity. The altercation involved verbal and physical exchanges, but neither resident was harmed. The facility initially reported the incident but did not submit the follow-up investigation results within the required timeframe. The Nursing Home Administrator (NHA) was unable to provide a reason for the delay and later admitted confusion regarding the reporting requirements. In the second incident, an allegation of potential misappropriation of $60 from a resident was not reported to the state agency within the required 5 days. The self-report was submitted 9 days after the incident occurred. The NHA attributed the delay to a misunderstanding of the state's reporting requirements, as they had previously worked in a different state with different regulations. No additional information was provided by the facility regarding the delay in reporting this incident.
Failure to Implement PASARR Recommendations for Specialized Services
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into the assessment, care planning, and transitions of care for a resident with developmental disability needs. The resident, identified as R52, was admitted with multiple diagnoses including cerebral palsy, major depressive disorder, and developmental disorder. The PASARR Level 2 determination, completed by a Qualified Intellectual Disabilities Professional (QIDP), indicated that R52 required specialized services to address developmental disability needs, including assistance with activities of daily living and encouragement in learning new skills. Despite these recommendations, the facility did not adequately incorporate them into R52's care plan. The review of R52's individual plan of care showed that while some aspects of care were addressed, such as impaired mobility and assistance with activities of daily living, there was no evidence of a comprehensive plan for specialized services as recommended by the PASARR. The surveyor's observation of R52's room revealed a lack of posters that were supposed to be part of the specialized services, and the Director of Social Services (DSS) admitted to not being aware of the specific needs for specialized services or how to incorporate them into the care plan. The facility's failure to develop and implement a plan for R52's specialized services needs was further highlighted during an interview with the DSS, who acknowledged a lack of experience with residents requiring such services and expressed uncertainty about the interventions needed. As of the time of the survey exit, the facility had not provided additional evidence of a developed plan to address R52's specialized service needs, nor could they explain why a reevaluation had not been conducted.
Incomplete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to ensure a complete baseline care plan was developed and addressed all of a resident's needs within 48 hours of admission. The resident, who was admitted with a primary diagnosis of paraplegia and other conditions such as morbid obesity and chronic respiratory failure, had a physician order for enabler bars to assist with self-positioning. However, the baseline care plan did not include the enabler bars under the Focus, Goal, or Interventions sections, despite the resident's need for them to improve bed mobility. The deficiency was identified when a surveyor observed the enabler bars on the resident's bed and noted that the baseline care plan lacked mention of them. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including necessary healthcare information and interventions for the resident's current needs. The omission was confirmed by the Regional Nurse, who agreed that the enabler bars should have been included in the baseline care plan. The facility did not provide additional information on why the baseline care plan was incomplete.
Failure to Ensure Resident's Use of Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, who was reviewed for communication with the use of hearing aids, received the necessary treatment and assistive devices to maintain their hearing abilities. The resident, who has severe cognitive impairment and a history of severe sensorineural hearing loss, was observed multiple times without their hearing aids. Despite having a care plan in place that included recommendations for audiology consultations and the use of hearing aids, there was no documentation indicating that the resident refused to wear the hearing aids. The resident was seen by an audiologist who confirmed the need for hearing aids and provided instructions for their use and maintenance. During the survey, it was noted that the resident's hearing aids were not in use, and the resident expressed unawareness of their existence. The facility staff, including a registered nurse, were unable to locate the hearing aids, and there was no documentation in the electronic medical record regarding the daily refusal or use of the hearing aids. The facility's failure to ensure the resident's hearing aids were used as prescribed resulted in the resident experiencing difficulty in communication and an inability to hear conversational speech.
Deficiency in Continence Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to restore continence for a resident, identified as R19, who was reviewed for bowel and bladder incontinence. R19 was admitted with multiple diagnoses, including type 2 diabetes, morbid obesity, and chronic obstructive pulmonary disease, and was noted to be incontinent of bowel and bladder. Despite being cognitively intact with a BIMS score of 13, the facility did not develop a comprehensive plan of care for R19's bowel incontinence, nor did they attempt a toileting program for urinary incontinence upon admission. The facility's assessments and documentation were inconsistent and incomplete. The admission assessment indicated R19 was continent of bowel, but subsequent evaluations and nursing notes documented bowel incontinence. The care plan for R19 addressed bladder incontinence but failed to include a plan for bowel incontinence. Additionally, the facility did not conduct a comprehensive assessment to determine the type of urinary incontinence or develop a pattern to address it. The lack of a structured toileting program and comprehensive assessment contributed to the deficiency. Interviews with staff, including an RN Consultant, revealed that there was an acknowledgment of the need for patterning for bowel and bladder incontinence, but this was not implemented. The facility's documentation, such as the 3-day bowel and bladder tracker, was inadequate as it did not indicate the resident's incontinence status. The facility's failure to comprehensively assess and address R19's incontinence issues led to the deficiency noted by the surveyors.
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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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