Burnett Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grantsburg, Wisconsin.
- Location
- 257 W St George Ave, Grantsburg, Wisconsin 54840
- CMS Provider Number
- 525558
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Burnett Medical Center during CMS and state inspections, most recent first.
A resident with atrial fibrillation, aortic valve insufficiency, CHF, and moderate cognitive impairment experienced a significant change in condition, including new weakness, confusion, labored respirations, a flaccid left arm, unequal and weak left hand grasp with swelling, and disorientation. Staff documented the event and contacted a family member, who agreed the resident would remain in bed rather than go to the ER, but there was no documentation that the provider was notified. The IDON and an RN confirmed in interviews that the physician should have been called for this change in condition, and facility policy required prompt notification of the attending physician or provider for significant changes in physical, emotional, or cognitive status.
A resident with CHF, chronic kidney disease, and a history of UTIs, and with moderately impaired cognition per BIMS, experienced a change in condition characterized by altered talking and walking ability and incontinence while sitting in a chair. After a family member requested hospital evaluation, the resident was sent to the ER and was admitted with sepsis. The IDON could not locate any transfer notice for this episode, despite acknowledging that a transfer notice including nursing assessment, vital signs, and other pertinent information should have been completed before transfer. Review of facility policy showed that changes in condition and events must be fully and accurately documented, but no such transfer documentation was found for this resident.
Two residents were affected by a failure to maintain complete and accurate medical records when a fall incident was not fully documented. A resident with cardiac conditions and moderate cognitive impairment fell from bed after tripping on blankets, and an incident note recorded the fall, lack of visible injury, and notifications to the physician and family, but omitted vital signs and neuro checks at the time of the event. An RN later reported having performed initial and subsequent neuro checks but did not document them until two days later due to a busy shift, and the IDON confirmed that the record was incomplete and that the assessments should have been recorded at the time of the fall.
A resident with brittle diabetes did not consistently receive insulin and hypoglycemia treatment as ordered, with staff administering alternate doses based on the resident's requests and failing to notify the provider of medication refusals or abnormal blood glucose levels. Documentation was lacking for provider communication and follow-up actions after both hypoglycemic and hyperglycemic events, and interviews confirmed that staff were not adhering to facility policy or physician orders regarding diabetic management.
The facility failed to maintain an effective infection control program, with incomplete infection surveillance logs and improper use of PPE. Staff were observed mishandling medications and neglecting hand hygiene during wound care, compromising infection control standards.
A survey found that a facility failed to label medications with open dates, leading to potential use of expired drugs for several residents. Insulin pens, Timolol drops, and other medications lacked proper labeling, with pharmacy labels covering expiration dates. Staff interviews confirmed the oversight, acknowledging the risk of administering expired medications.
The facility failed to maintain residents' dignity during meal assistance, as staff used clothing protectors instead of napkins to wipe residents' faces. Three residents with cognitive and physical impairments were affected, with staff repeatedly using clothing protectors inappropriately during meal times. The DON acknowledged this practice was not respectful.
A resident's APOA reported a missing personal item, but the facility failed to document, investigate, or resolve the grievance as per its policy. Despite acknowledging the issue, staff did not consider it a grievance, and no documentation was found. The Social Services Manager admitted the practice did not align with the facility's grievance policy.
A resident with an indwelling catheter did not have a comprehensive care plan developed by the facility. Despite the nursing staff being aware and providing care, the care plan lacked documentation of the catheter and necessary care instructions. The oversight was attributed to the catheter's temporary nature.
The facility failed to revise and implement care plans for two residents, leading to deficiencies in fall prevention. One resident's care plan required 30-minute checks after falls, but there was no documentation to confirm these were done. Another resident's care plan required 15-minute checks, but again, no evidence was found to verify completion. The DON acknowledged the lack of documentation for these interventions.
A resident with multiple diagnoses had a pharmacy recommendation to lower their Seroquel dose that was not acknowledged by a physician. The facility's RN and DON could not provide documentation of a provider response, citing delays from the VA hospital and the DON's newness in the role as contributing factors.
A resident was prescribed and administered an antibiotic for a UTI without documented symptoms or lab results to justify its use, contrary to the facility's Antimicrobial Stewardship Program and Loeb criteria. The Infection Preventionist acknowledged that physicians sometimes prescribe antibiotics based on their judgment, even if it conflicts with the policy, posing a potential risk to resident safety.
The facility exceeded the acceptable medication error rate, with errors involving insulin and Morphine administration. An RN failed to hold an insulin injection for the required time, and an LPN did not check the expiration date of Morphine. The DON confirmed expectations for medication labeling and administration, but specific policies were lacking.
Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider of a significant change in condition for one resident. The resident was admitted with atrial fibrillation, aortic valve insufficiency, and congestive heart failure, and had a BIMS score of 10/15, indicating moderately impaired cognition. A Plan of Care note documented that around 3:00 AM the resident experienced weakness and confusion, with difficulty walking observed by a CNA. The nurse’s assessment noted labored, puffing respirations, the resident feeling scared but denying pain, a flaccid left arm, unequal and very weak left hand grasp with notable swelling, incorrect responses to orientation questions except for name, and no facial droop with pupils equal and reactive. The resident was assisted via wheelchair to the bathroom and back to bed and was able to swallow water without difficulty. The same Plan of Care note documented that a call was placed to a family member, who agreed with the resident remaining in bed at the facility rather than going to the ER. However, there was no documentation that the provider was notified of this significant change in condition. The Interim DON confirmed in interview that the provider should have been notified as soon as possible. A former DON (now RN) stated that any change in condition should prompt a call to the physician, that she did not recall receiving any call about this event, and that staff should not have called the family and taken direction from them first. Review of the facility’s policy “Change in a Resident’s Condition or Status” stated that the nurse will notify the attending physician or provider when there is a significant change in the resident’s physical, emotional, or cognitive condition or a need to significantly alter medical treatment, which did not occur in this case.
Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The deficiency involves the facility’s failure to provide a transfer form to the hospital at the time of transfer for one resident. The resident was admitted with diagnoses including congestive heart failure, chronic kidney disease, and a history of urinary tract infections. The admission MDS showed a BIMS score of 10/15, indicating moderately impaired cognition. A plan of care note documented that the resident was found sitting in a chair with the light on and was not within normal limits for talking and walking ability, and that she had soiled herself in the chair. A family member was called and requested that the resident be taken to the emergency room for evaluation. The former DON stated that the night nurse alerted her that the resident was not doing well, and the resident was sent to the ER, where she was admitted with sepsis. The Interim DON reported being unable to find any evidence that a transfer notice was completed, despite stating that a transfer notice should have been done prior to going to the ER and should have included a nursing assessment, vital signs, and other pertinent information. Review of the facility’s “Charting and Documentation” policy indicated that all services provided, changes in condition, and events involving the resident must be documented in the medical record, and that documentation must be objective, complete, and accurate. The absence of a transfer notice for this resident at the time of hospital transfer constituted the cited deficiency.
Incomplete and Delayed Documentation of Fall and Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced a fall. The resident was admitted with diagnoses including atrial fibrillation, aortic valve insufficiency, and congestive heart failure, and had a BIMS score of 10/15, indicating moderately impaired cognition. An incident note in the EMR documented that the resident fell out of bed when blankets fell onto the floor and the resident tripped on them, after which the blankets were picked up and the resident was placed back in bed, with no cuts or bruises noted and the physician and son notified. However, this incident note did not include a complete and accurate description of the fall, as it lacked documentation of vital signs and neurological checks at the time of the fall. During interviews, the IDON confirmed that the resident’s medical record was not complete and accurate and that neurological checks should have been documented at the time of the fall rather than two days later. An RN reported being on duty at the time of the fall and described that the resident, who had anxiety at night and transferred independently to the bathroom, was found lying on their stomach near the side of the bed toward the foot of the bed, wrapped in multiple comforters. The RN stated that the resident did not hit their head and that initial and subsequent neurological checks were performed but not documented at the time due to a busy shift, which the RN acknowledged as a mistake. Review of the EMR showed that the neurological checks were not entered into the record until two days after the fall, confirming the incomplete and delayed documentation related to the incident.
Failure to Follow Physician Orders and Notify Provider for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident with brittle diabetes received care and treatment in accordance with professional standards of practice. The resident had multiple physician orders for blood glucose monitoring, insulin administration, and hypoglycemia management, as well as care plans specifying the need for strict adherence to these orders and prompt provider notification in the event of medication refusal or abnormal blood glucose levels. Despite these directives, the resident frequently refused prescribed doses of insulin, and staff administered alternate doses without provider authorization. There was no documentation that the provider was notified of these refusals or of the administration of doses outside of the ordered parameters. Additionally, the resident experienced multiple episodes of both hypoglycemia and hyperglycemia, with blood glucose readings falling below 70 mg/dL and rising above 400 mg/dL on several occasions. Facility policy required immediate provider notification and specific interventions in these situations, but the medical record lacked evidence that these steps were consistently taken. In several instances, glucose tablets were administered in doses different from those ordered, and there was no documentation of provider notification or follow-up blood glucose checks as required by policy. The MAR also showed that staff did not always document follow-up actions or provider communication after abnormal blood glucose readings or medication refusals. Interviews with nursing staff and facility leadership confirmed that staff were not consistently following provider orders or facility policy regarding medication administration and provider notification. Nurses reported administering insulin and glucose tablets in amounts requested by the resident rather than as ordered, and they did not routinely notify the provider of refusals or abnormal blood glucose levels. The DON and CEO acknowledged that staff were expected to follow provider orders and communicate changes in the resident's condition, but this was not consistently occurring in practice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by several deficiencies observed during the survey. The infection surveillance log was incomplete, missing documentation for specific dates and lacking critical information such as symptom resolution dates, isolation precaution dates, and antibiotic start and end dates. This oversight was attributed to the absence of the Infection Preventionist (IP) and the lack of data from the previous year. The Minimum Data Set (MDS) Coordinator acknowledged the importance of accurate and complete infection surveillance to prevent potential outbreaks and identify areas of concern. Inappropriate use of personal protective equipment (PPE) was observed, with staff failing to properly don and doff PPE in accordance with facility policy. For instance, a Certified Nursing Assistant (CNA) was seen leaving a resident's room wearing PPE and disposing of it incorrectly, while another CNA entered a different resident's room with contaminated PPE. The Director of Nursing (DON) confirmed that staff should don PPE outside the room and doff it inside, with designated bins for dirty PPE, which was not followed in these instances. Hand hygiene practices were also found lacking, particularly during medication administration and wound care. A Licensed Practical Nurse (LPN) was observed handling medications with bare hands and failing to perform hand hygiene before and after medication preparation. Additionally, during wound care for a resident with a pressure ulcer, the LPN changed gloves without sanitizing or washing hands between changes, contrary to the facility's infection control policy. These actions compromised the facility's infection control standards and posed a risk of infection transmission among residents.
Medication Labeling Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles, specifically regarding the labeling of expiration dates on opened medications. During the survey, it was observed that several medications, including insulin pens and other drugs, lacked open date labels, and pharmacy labels were covering the manufacturing expiration dates. This issue was noted for seven residents, with medications such as Humalog insulin pens, Timolol drops, Levetiracetam, Lantus insulin pens, Tresiba insulin pens, Admelog insulin pens, and Lorazepam being affected. The absence of open date labels on these medications could lead to the administration of expired drugs, as staff members were unable to determine when the medications were opened or when they would expire. Interviews with nursing staff, including an RN, an LPN, and the DON, revealed that there was an expectation for all opened medications to be labeled with the open date to prevent the use of expired medications. However, this practice was not consistently followed, as evidenced by the observations made during the survey. The staff acknowledged the oversight and indicated that the medications had been used without the necessary labeling, which could potentially compromise the effectiveness and safety of the medications administered to the residents.
Residents' Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal assistance, as observed by surveyors. Three residents, each with varying degrees of cognitive and physical impairments, were affected by this deficiency. A registered nurse and a licensed practical nurse were observed using clothing protectors to wipe the residents' faces instead of using napkins, which is not in line with maintaining the residents' dignity. This practice was noted during meal times in the dining room, where the staff repeatedly used the clothing protectors for wiping the residents' mouths and faces. Resident 17, who had moderate cognitive impairment and required assistance with eating, was observed being assisted by a registered nurse who used the clothing protector instead of a napkin. Similarly, Resident 22, who was completely dependent on staff for eating due to cerebral palsy, was assisted by both a licensed practical nurse and a certified nursing assistant, both of whom used the clothing protector inappropriately. Resident 7, with moderate cognitive impairment and limited range of motion, was also subjected to the same practice by a certified nursing assistant. The Director of Nursing acknowledged that this practice was not respectful of the residents' dignity.
Failure to Document and Resolve Grievance for Missing Item
Penalty
Summary
The facility failed to investigate, resolve, and document the resolution of a grievance for a resident identified as R28. The resident's Activated Power of Attorney (APOA) reported a missing personal item, specifically a blue luggage bag, shortly after the resident's admission. Despite reporting the missing item to numerous staff members, the APOA did not receive any written documentation to fill out, nor was there any documentation of investigation findings or a resolution offered. The facility's grievance policy, which mandates the oversight of grievances by Social Services and the Director of Nursing (DON), was not followed in this instance. Interviews with facility staff, including the Social Services Manager (SSM) and a Registered Nurse (RN), revealed that the missing item was acknowledged but not documented as a grievance. The SSM, who had been in the role for about three months, stated that missing items were not considered grievances and were not included in the grievance log. The facility's practice was to handle missing items through unit staff, who would complete a missing item form and attempt to resolve the issue. However, no such form was found for R28's missing bag, and the grievance log showed no entries since December 2023. The SSM admitted that the current practice did not align with the facility's grievance policy, acknowledging the negative impact on residents' rights.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling catheter. The resident, who was admitted with diagnoses including syncope, orthostatic hypertension, atrial fibrillation, and repeated falls, had a BIMS score indicating cognitive intactness and was noted to be continent without an indwelling catheter according to the most recent MDS. However, the resident had a 16 French urinary catheter placed for urinary retention during a urology clinic visit, with instructions for continued catheter care until a follow-up appointment. Despite this, the resident's care plan did not reflect the presence of the catheter or the necessary care instructions. Interviews and record reviews revealed that the nursing staff were aware of the catheter and were providing care, but this was not documented in the care plan. The Director of Nursing acknowledged the oversight, attributing it to the temporary nature of the catheter. The resident confirmed the catheter's placement and the nursing staff's involvement in its care, but the lack of documentation in the care plan represents a deficiency in ensuring comprehensive care planning for the resident's needs.
Failure to Implement and Document Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure that care plans were revised and implemented to reflect changes in care for two residents, R12 and R22. R12, who was admitted with diagnoses including syncope, orthostatic hypertension, atrial fibrillation, and repeated falls, had a care plan that included interventions such as room checks every 30 minutes to 1 hour following a series of falls. Despite these interventions being documented in the care plan, there was no evidence that the checks were completed. The Director of Nursing (DON) confirmed that the previous DON did not have these interventions charted, and there was no documentation to verify that the checks were conducted. Similarly, R22, who was admitted with diagnoses including spinal stenosis, repeated falls, and osteoarthritis, had a care plan that required 15-minute checks following falls. Despite the care plan's requirements, there was no documentation to verify that these checks were completed. The DON indicated that although staff were performing the checks, there was no evidence in the charting to confirm this. This lack of documentation and verification of care plan interventions led to the identified deficiencies.
Failure to Acknowledge Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendation reports were acknowledged by a physician for one of the residents reviewed. Resident R12, who was admitted with diagnoses including syncope, orthostatic hypertension, atrial fibrillation, mood disorder, and repeated falls, had a pharmacy recommendation to lower the dose of Quetiapine fumarate (Seroquel) that was not acknowledged or acted upon by a physician. This recommendation, initially made on 06/19/24, remained pending without a response from the provider as of the survey date. During the survey, the Registered Nurse (RN) and the Director of Nursing (DON) were unable to provide documentation of a provider response to the pharmacy's recommendation. The RN indicated that the responsibility for following up on pharmacy recommendations lies with the DON. The DON acknowledged the delay in response from the Veteran Affairs (VA) hospital provider and admitted to being new in the role, which contributed to the oversight in addressing the pharmacist's recommendation.
Unnecessary Antibiotic Use Without Indication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically antibiotics, for a resident reviewed for antibiotic use without adequate indication. The resident, who was admitted with multiple diagnoses including COPD, heart failure, atrial fibrillation, diabetes mellitus, and was under hospice care, was prescribed and administered cefuroxime avetil for a UTI without documented symptoms or laboratory results to justify the antibiotic use. The facility's policy, based on the Antimicrobial Stewardship Program and Loeb criteria, requires that antibiotics be prescribed only when appropriate signs and symptoms are present, and typically after receiving urinalysis results. The surveyor's review of the resident's records revealed that the antibiotic was started before any urinalysis or culture results were available, and no symptoms were documented to indicate a UTI. The Infection Preventionist confirmed that the facility's policy is to wait for urinalysis results before prescribing antibiotics, but acknowledged that physicians sometimes prescribe antibiotics based on their judgment, even if it conflicts with the policy. This practice was recognized as a conflict with the facility's policy and a potential risk to resident safety and health due to the misuse of antibiotics.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in an 11.54% error rate during a medication pass observation. This deficiency involved two residents, R12 and R15, and included 26 opportunities with 3 medication errors. Registered Nurse (RN) D administered insulin to R12 without checking the expiration date and failed to hold the insulin injection in the abdomen for the recommended 10 seconds, leading to insulin dribbling down the resident's abdomen. RN D incorrectly believed that holding the insulin pen was unnecessary for doses under 50 units. Licensed Practical Nurse (LPN) C administered Morphine sulfate to R15 without verifying the expiration date, as the pharmacy label obscured the manufacturing expiration date. LPN C acknowledged the oversight and the importance of checking expiration dates before administering medications. The Director of Nursing (DON) B confirmed the expectation for labeling open medications with an open date and holding insulin injections for at least 10 seconds, although the facility lacked specific policies on these procedures.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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