Careview Health And Rehab Of Minocqua
Inspection history, citations, penalties and survey trends for this long-term care facility in Minocqua, Wisconsin.
- Location
- 9969 Old Hwy 70 Rd, Minocqua, Wisconsin 54548
- CMS Provider Number
- 525678
- Inspections on file
- 39
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 57 (1 serious)
Citation history
Health deficiencies cited at Careview Health And Rehab Of Minocqua during CMS and state inspections, most recent first.
The facility failed to ensure resident dignity and self‑determination when a video camera with audio capability, installed by a resident’s POA in a shared room, remained in use without documented consent from either resident or their representatives. A cognitively impaired resident and that resident’s guardian were not properly informed of the camera’s presence, and the guardian later reported being unaware and uncomfortable with it. Record review showed no signed consent for the camera from the roommate’s POA and no documentation of any discussion at a care conference, and neither resident’s care plan addressed the ongoing audio/visual surveillance in the room.
A resident admitted with confusion, a history of falls, and moderately impaired cognition was care planned as a fall risk with limited initial interventions, but the care plan was not updated after multiple subsequent falls, including one with major injury. Although new fall interventions (such as a "Call for Help" sign and changes in mobility equipment placement) were documented in other records and observed in the room, they were not incorporated into the formal care plan. Staff described different fall interventions based on report and observation rather than a unified, updated care plan, and the DON confirmed that nursing staff had not revised the care plan to include the post-fall interventions.
A resident with multiple comorbidities and identified risk for pressure ulcers developed a left heel pressure injury that was not comprehensively assessed by nursing staff, was initially misdocumented as being on the right heel, and did not trigger timely updates to the care plan. When the wound care MD ordered more intensive treatment, including Betadine and twice-daily dressing changes, nursing staff failed to transcribe and implement these orders, continuing a less frequent regimen. Comprehensive wound assessments between weekly MD visits were not performed, and facility leadership acknowledged that nurses relied on limited SBAR documentation instead of full assessments. The heel wound progressed to a Stage 4 PI with osteomyelitis and sepsis, and hospital records confirmed a diagnosis of left calcaneal osteomyelitis and Stage 4 heel PI, supporting the finding that the facility did not provide pressure ulcer prevention and treatment consistent with professional standards.
Surveyors found that the facility did not ensure an RN was on duty for at least eight consecutive hours on multiple days, based on PBJ staffing data and review of staff schedules and nurse postings. Interviews with administration revealed that daily staffing postings were created by a receptionist and not manually updated to reflect changes, and that internal schedules, which were not publicly posted, were relied upon instead. Although documentation was later provided to show RN coverage on one of the questioned days and administration reported that corporate RNs rotated to provide coverage, the facility could not produce records confirming eight hours of RN coverage on three specific days, affecting all residents.
Surveyors found that the facility failed to provide required bed-hold and transfer/discharge notices to multiple residents during hospital transfers. Cognitively intact and moderately impaired residents were transferred for changes in condition and hip pain without receiving written notice of the bed-hold policy, reserve payment terms, or specific reasons for transfer/discharge. In some cases, bed-hold forms were signed by managed care organization staff but lacked required details such as the daily reservation rate, and one resident did not receive a new bed-hold notice for a later hospital transfer. During the survey, the social worker responsible for these processes was unavailable, and leadership staff could not clearly describe the transfer/discharge notification process.
A resident’s family reported multiple missing personal items, including a cell phone, wallet with cash, shoes, grabbers, and a box containing keys. The facility’s policies required prompt reporting of misappropriation to appropriate agencies and a thorough investigation with interviews of the resident, reporter, witnesses, and involved staff. However, the facility did not report the allegation to the State Agency, delayed starting its investigation, and ultimately produced only a single grievance form documenting limited room and laundry searches and no detailed investigative steps, while the missing property was never located.
The facility failed to conduct timely and thorough investigations into two separate allegations involving residents. In one case, a resident’s family reported missing personal items, including cash, but the facility delayed starting the investigation, documented only a room and laundry search, did not interview staff or other residents, and was unable to locate the property. In the other case, a resident with moderate cognitive impairment and a history of falls developed significant pelvic fractures of unknown origin; the facility’s investigation consisted of limited staff interviews, no direct interview with the resident, no complete physical/emotional assessment, incomplete documentation, and no clear determination of how or why the injury occurred. These actions did not follow the facility’s abuse prevention and investigation policies, which require prompt, comprehensive investigations and interviews of all relevant parties.
Two residents did not receive care according to physician orders and professional standards. One resident with bilateral lower extremity wounds and toe amputations had active TAR orders for nightly dressing changes, infection monitoring, and documentation of drainage and pain, but there was no TAR documentation of dressing changes or wound assessments over multiple consecutive days, the care plan did not address wound care, and the resident reported dressings had not been changed since admission. Another resident with hypertension and chronic kidney disease fell from a recliner and was found with low BP; the NP ordered hourly BP monitoring and holding of BP medications until BP normalized, but there was no documentation of ongoing BP checks or that medications were held as ordered, beyond MAR entries, and the DON could not locate evidence that these monitoring orders were followed.
Two residents did not receive required safety interventions to prevent accidents. One resident with dementia and severe cognitive impairment, assessed as an elopement risk and care planned for a wanderguard on the left wrist with shift checks documented on the TAR, was repeatedly observed without a wanderguard on any limb or wheelchair, while staff documentation and interviews showed uncertainty and inconsistency about the device’s presence. Another resident with moderately impaired cognition and a care plan requiring a two‑person transfer with a gait belt was observed being transferred from the toilet to a wheelchair by a single CNA without a gait belt, and the CNA reported not using a gait belt for that resident’s transfers and believing the care plan did not require it.
The facility did not ensure that daily nurse staffing postings accurately reflected the total and actual hours worked by licensed and unlicensed nursing staff per shift, potentially affecting all 47 residents. A posted Direct Care Report in the lobby was outdated, and review of schedules and postings over several weeks showed that staffing changes recorded on internal schedules were not consistently updated on the public staff postings. The NHA and assistant NHA reported that the receptionist posts staffing information once in the morning after updating the census, and that subsequent staffing changes are not manually updated on the posted report.
A resident admitted after hospitalization for severe groin infection did not receive prescribed wound VAC therapy or vancomycin solution as ordered in hospital discharge instructions. Facility staff were unaware of the specific wound care needs, did not consult a physician when supplies were unavailable, and failed to document or provide ordered treatments. The wound VAC was delayed, and the wound became contaminated with stool, leading to the resident being sent to the emergency room for care.
A resident admitted after hospitalization for severe groin infection and wound debridement did not have a baseline care plan developed for wound care within 48 hours, despite physician orders for wound VAC and vancomycin irrigation. The care plan only addressed the Foley catheter and advanced directives, and an LPN confirmed the omission of wound care planning.
A resident with a severe groin wound requiring a wound VAC and vancomycin irrigation did not receive care as ordered. Facility staff failed to implement a baseline care plan for the wound, did not order or apply the wound VAC in a timely manner, and did not administer the prescribed vancomycin solution. The wound was left exposed, became contaminated with stool, and the resident experienced significant pain, ultimately requiring transfer back to the hospital.
The facility did not have an RN serving as DON as required, instead appointing an LPN to the role and leaving the position vacant for a period. During this time, multiple complaint investigations resulted in citations for issues such as pharmacy services, catheter care, and medication errors, and the facility experienced a high number of grievances.
The facility did not timely or adequately request a waiver when unable to recruit a registered nurse for the DON position. After the previous DON resigned, the facility was without an RN in this role and failed to provide the State Agency with requested evidence of recruitment efforts or assurances for resident safety. The acting DON did not meet RN requirements.
The facility's call light system was not fully operational, with auditory alarms and nurse's station alerts nonfunctional for several weeks. Multiple residents and family members reported excessive wait times for assistance, and some residents had to leave their rooms to seek help. Staff confirmed the system's deficiencies, and maintenance efforts to repair the outdated system were unsuccessful, as documented by invoices and grievance records.
Licensed staff did not immediately initiate CPR for a resident with a full code status who was found unresponsive and not breathing. The CNA who discovered the resident left the room to find a nurse rather than calling for help or starting CPR, and the LPN who responded also did not begin CPR, instead instructing the CNA to get the RN. CPR was only started after the RN arrived and the resident was repositioned, resulting in a delay that was not in accordance with facility policy or the resident's documented code status.
A resident with a PICC line for IV antibiotics did not have documented orders or records for routine line care, including flushing, dressing changes, or site monitoring. Staff confirmed the lack of standing orders, and the omission led to a line occlusion requiring hospital intervention.
Two residents did not receive their scheduled medications at the prescribed times, with doses of clonazepam, baclofen, buspirone, and gabapentin administered either hours late or too close together. Staff interviews revealed inconsistent understanding of medication timing policies, and facility records showed that required administration windows were not followed.
A resident with a diagnosis of gram-positive bacteremia did not receive two scheduled doses of IV Vancomycin because the medication was not available in the facility. Despite pharmacy communication and refaxing of orders, the first dose was not administered until two days after the prescribed start date, and the nurse practitioner was not informed of the missed doses. Facility policy required timely administration of medications, which was not followed in this case.
A resident with multiple medical conditions and moderate cognitive impairment was found unresponsive in a position suggesting a possible injury of unknown origin and required CPR. Staff did not complete an incident report, and the QAA committee did not identify, investigate, or review the adverse event, despite facility policy requiring such actions for negative outcomes and adverse events.
Three residents with indwelling catheters did not receive care consistent with professional standards, as staff failed to consistently monitor, document, and report urinary output per physician orders and facility policy. In one case, a resident with a suprapubic catheter experienced two days of increased incontinence and lack of catheter drainage, leading to hospitalization for a severe UTI, with no evidence of timely assessment or provider notification. Similar documentation and assessment failures were found for two other residents.
The facility did not provide required Bedhold and transfer notices, nor did it notify the Ombudsman, when a resident with a Power of Attorney, a resident with a legal guardian, and a resident with multiple sclerosis and neurogenic bladder were transferred to the hospital following changes in condition. The Nursing Home Administrator confirmed these notifications were not given.
Surveyors observed that drugs and biologicals, including lorazepam and eye drops, were stored in unlocked refrigerators and lacked proper labeling. Expired intermittent catheters were also found in the medication storage room. Staff, including a CMA and an LPN, were unable to demonstrate knowledge of expiration dates or proper storage procedures, and the DON confirmed the presence of expired and improperly stored items.
The facility did not consistently monitor or record internal food temperatures during meal service, resulting in a resident being served over-easy eggs at 107.2°F, below the required 135°F. Staff did not check the temperature of the eggs before serving, and food logs only documented temperatures at the start and end of service, not during tray delivery.
Two residents did not receive medications as ordered due to transcription errors and missed doses, with one resident receiving an incorrect Aspirin dose for several weeks and another missing evening medications on two occasions without proper documentation in the eMAR.
A resident with a history of urinary tract infections and chronic catheter use had a urinalysis ordered by a urologist, which revealed significant bacterial growth. The facility did not notify the ordering urologist or the primary provider of these results, as the order was incorrectly placed under the medical director. Four days later, the resident was hospitalized for sepsis, and staff interviews confirmed that the providers were not made aware of the lab findings.
The facility did not update its facility-wide assessment to reflect a significant increase in resident census, resulting in insufficient staffing levels. Staff interviews revealed that CNAs and RNs struggled to manage the increased workload, leading to delays in resident care and staff resignations. The Nursing Home Administrator acknowledged the outdated assessment and staffing ratios, which were based on previous census figures.
Two residents in the facility did not receive appropriate care according to their care plans and professional standards. One resident with CHF did not have necessary assessments or lab tests completed, leading to hospitalization for CHF exacerbation and myocardial infarction. Another resident with multiple wounds did not receive timely skin assessments or wound care, resulting in hospitalization and amputation. Staff interviews revealed lapses in monitoring and documentation, contributing to the residents' deteriorating conditions.
The facility failed to ensure proper food handling and sanitization practices, risking foodborne illnesses for all 28 residents. Observations showed improper glove use, lack of hand hygiene, and inadequate hair restraints by staff. Additionally, food items in the kitchen were not labeled or dated, violating facility policies. Interviews confirmed expectations for labeling and monitoring food items, but these were not consistently followed.
A resident with a history of heart conditions experienced difficulty breathing and was transferred to the ED without immediate notification to their physician. The facility failed to document or inform the physician of the resident's condition and transfer, which was only communicated the following day, contrary to standard practice expectations.
A resident with schizoaffective disorder and prescribed psychotropic medications did not receive a required PASRR Level II screening. Although a Level I screening indicated the need for further evaluation, and form F-20822 was completed recommending short-term exemption, no specific exemption was chosen, and the necessary Level II screening was not conducted. The Nursing Home Administrator confirmed the oversight.
A resident at risk for pressure injuries did not receive adequate care as the facility failed to apply prescribed heel protector boots consistently and did not conduct thorough skin assessments. The resident was admitted with multiple pressure injuries, but the facility did not document their locations, sizes, or stages, leading to unclear progression of the injuries. Staff interviews revealed inconsistencies in applying the boots and documenting their application.
A facility failed to implement a resident's ambulation program, as outlined in their care plan, to maintain mobility and minimize fall risk. Despite the resident's medical conditions, staff did not offer ambulation opportunities, and the facility lacked a maintenance or restorative program. Observations showed the resident was transported in a wheelchair without being offered to walk, and no evidence of the walking program was found in the resident's records.
A facility failed to assess a resident with an indwelling catheter for its removal, contrary to their policy. The resident, admitted with conditions like benign prostatic hyperplasia and UTI, was not evaluated for urinary continence or a toileting program. The DON admitted that routine catheter changes did not align with standards, and the facility lacked documentation to justify the catheter's continued use.
The facility failed to maintain proper infection control practices for two residents. One resident with an indwelling catheter was under Enhanced Barrier Precautions, but a CNA did not wear a gown as required. Another resident tested positive for COVID-19, but there was no droplet precaution signage on the door, leading to staff potentially entering without proper PPE. The Director of Nursing and an RN confirmed these lapses in protocol.
Failure to Obtain Consent and Inform Residents Regarding In‑Room Audio/Video Surveillance
Penalty
Summary
The facility failed to treat two residents with respect and dignity and to promote their quality of life by not properly managing audio and visual surveillance in their shared room. One resident with moderate cognitive impairment, who had a guardian appointed to assist with decision making, was admitted to a room already containing a video monitoring camera placed by the roommate’s activated POA. The camera was located on top of the roommate’s closet, pointed toward the corner of the roommate’s side of the room, and had audio capability. The facility did not have access to the surveillance, but the roommate’s POA could observe both video and audio, allowing them to hear conversations occurring anywhere in the room, including those involving the cognitively impaired resident. Surveyor review of records found no evidence that the cognitively impaired resident or the resident’s guardian had been informed of or consented to the presence of the camera, and no documentation that this was discussed at a care conference, despite the NHA’s statement that Social Services had done so. The guardian confirmed she was not aware of the camera and was not comfortable with it being in the resident’s room. Additionally, there was no consent in the roommate’s record for the camera, despite an email chain months earlier indicating the need for such consent from the roommate’s POA. Neither resident’s care plan included any information or interventions related to the video surveillance in their room.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current fall risk interventions following multiple falls. The resident was admitted after hospitalization for increased confusion and falls at home, had a BIMS score indicating moderately impaired cognition, and had an activated POA for decision-making. Initial assessments documented no elopement risk and a low fall risk, and the care plan identified increased risk for falls related to deconditioning, ataxia, recent fall, muscle weakness, and noncompliance with transfer assistance, with interventions such as keeping the call light within reach and therapy evaluation and treatment. Despite this, the resident experienced several falls, including a fall with major injury resulting in a fractured pelvis and subsequent falls in the room. After each fall, new fall interventions were documented on eINTERACT forms and in progress notes, such as placing a “Call for Help” sign and removing the walker when the resident was in bed with the wheelchair at bedside, but these interventions were not incorporated into the resident’s care plan. Surveyor observations confirmed the presence of the “Call for Help” sign and the walker’s placement in the room, and staff interviews showed varying understandings of the resident’s fall interventions, including toileting after meals, use of a floor mat, and keeping the bed in the lowest position. The DON confirmed that fall interventions documented after each fall had not been added to the care plan and that nurses were responsible for updating the care plan after completing eINTERACT forms. The surveyor determined that the facility did not revise the resident’s care plan to reflect current interventions to reduce fall risk.
Failure to Prevent and Properly Treat a Heel Pressure Injury Leading to Stage 4 Ulcer and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury (PI) prevention and treatment consistent with professional standards of practice for one resident, resulting in the development and deterioration of a left heel PI. The resident was admitted after hospitalization for sepsis with multi-organ failure and had multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease stage 3, unspecified dementia, hypertension, and heart failure. The initial care plan identified the resident as at increased risk for pressure ulcer development and included interventions such as a pressure-reducing mattress, administering treatments as ordered, and using barrier creams with each incontinent episode. A comprehensive MDS indicated the resident was at risk for pressure ulcer development, but the surveyor could not obtain documentation of the assessment tool or score used to determine this risk. Subsequently, the resident developed skin integrity issues, including a Stage 3 pressure wound on the right medial buttock that was later resolved. Later, an SBAR form documented a new wound to the heel, described as an open area measuring 8 cm by 5 cm, with a bandage applied and pressure boots placed while in bed. The wound was actually on the left heel, but it was incorrectly documented as the right heel. At that time, there was no comprehensive wound assessment completed that described wound characteristics beyond basic measurements. A treatment order was entered on the TAR for the left heel to cleanse with normal saline, pat dry, apply foam dressing, and secure with Kerlix once daily at bedtime, with daily assessment of drainage, appearance, and surrounding skin. The surveyor could not find evidence of a comprehensive wound assessment for the left heel until a later date. When the wound care physician evaluated the resident, the left heel blister had ruptured and was an open wound with nonviable tissue and necrosis, and debridement was performed. The physician ordered a new treatment plan including Betadine and dressing changes twice daily and as needed, but the TAR was not updated and nursing continued the prior once-daily treatment without Betadine until a later date. The care plan was not updated to reflect the new left heel surgical wound or to include weekly treatment documentation and monitoring until well after the wound had developed. Facility nurses did not complete comprehensive wound assessments upon discovery of the new PI or between weekly physician visits, and the NHA stated the facility does not do comprehensive assessments, relying instead on SBAR forms, of which only one was completed for the new heel PI. Over time, the left heel wound progressed. Subsequent wound care notes documented changes in wound size and treatment modifications, including discontinuation of Betadine and initiation of Hydrofera Blue and other dressings. The resident was hospitalized and later returned with a Stage 4 pressure wound of the left heel, with specific measurements and new treatment orders including Hydrofera Blue, collagen powder, and hypochlorous acid solution. An additional hospital order directed topical Tobramycin Sulfate Injection solution to the left heel twice daily. Later, the resident was again sent to the ER for chills and rigors, with the wound gently packed and the physician noting the resident appeared septic with tachypnea and tachycardia. Hospital records documented sepsis secondary to streptococcus dysgalactiae bacteremia and left calcaneal osteomyelitis, with diagnoses including an open wound and Stage 4 PI of the left heel. The surveyor concluded that the facility failed to implement aggressive interventions to prevent PI development, failed to ensure treatment orders were transcribed and completed as ordered, and failed to complete comprehensive assessments upon discovery and during the course of the left heel PI, leading to an avoidable PI that deteriorated to Stage IV with osteomyelitis requiring hospitalization and IV antibiotics. Interviews with facility leadership confirmed these failures. The DON acknowledged that wound care orders from the wound care physician were not followed, the care plan was not updated, and that the expectation was for nurses to complete and document ordered wound treatments and update the care plan for changes and new interventions. The DON also stated that comprehensive wound assessments were performed by the wound care physician, which explained the lack of comprehensive wound assessment documentation by facility nurses. The NHA, when asked why comprehensive assessments were not completed with the development of the new heel PI and changes in treatment, stated that the facility does not do comprehensive assessments and instead uses SBAR forms for changes in residents, despite only one SBAR being completed for the new heel PI. These documented inactions and omissions formed the basis of the deficiency and the finding of immediate jeopardy.
Removal Plan
- Facility initiated education for all licensed nursing staff (RNs and LPNs) including: prompt identification and reporting of new pressure injuries; completion of comprehensive assessments upon discovery of a new pressure injury; completion of daily diabetic foot checks; accurate transcription, initiation, and completion of physician ordered treatments; implementation of aggressive pressure injury prevention and treatment interventions per standards of practice; education on notification of physician/NP of all new pressure injuries as well as any significant changes to pressure injuries.
- Licensed nursing staff completed competency validation related to pressure injury staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions.
- Facility conducted skin assessments and Braden scale assessments of all residents in the facility.
- Facility conducted TAR audits of residents to ensure wound treatments were completed as ordered.
- Facility reviewed resident wound treatment orders to ensure they were accurate and appropriate.
- Facility conducted wound round audits on all residents with wounds/pressure injuries.
Failure to Ensure Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Review of the PBJ Staffing Data Report for Quarter 4 of 2025 (July 1–September 30) showed four days within the quarter with no RN hours reported: 08/15/2025, 09/08/2025, 09/09/2025, and 09/14/2025. Further review of the facility’s staff schedules and nurse postings for the last 92 days of that quarter confirmed that on 08/15/2025 (Friday), 09/08/2025 (Monday), and 09/09/2025 (Tuesday), there was no RN scheduled for eight consecutive hours. The facility was unable to provide documentation to support that an RN worked at least eight consecutive hours on those three dates. During interviews on 01/14/2026, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing sheet in the morning after updating the census, and that the facility does not manually update the public posting to reflect subsequent staffing changes, relying instead on the internal schedule, which is not publicly posted. Later that day, the Assistant Nursing Home Administrator provided documentation supporting RN coverage for 09/14/2025 and stated that corporate RNs had been rotating to provide the required eight hours of RN coverage between 08/15/2025 and 09/14/2025. However, no additional records or documentation could be produced to verify RN coverage for 08/15/2025, 09/08/2025, and 09/09/2025, resulting in a finding that the facility did not ensure RN coverage for at least eight consecutive hours on those dates for all 47 residents.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold notices and transfer/discharge notices to residents or their representatives in connection with hospital transfers. Record review and interviews showed that five residents did not receive proper notification of the facility’s bed-hold policy, including information on reserve payment, and did not receive notice before transfer or discharge indicating the specific reason for the transfer/discharge. One cognitively intact resident (R43), who scored 15/15 on the BIMS, was transferred to the hospital on 1/5/26 with a summary sent, but the social worker reported there was no bed-hold notice for this transfer. Another resident (R8), with moderate cognitive impairment (BIMS 9/15), was admitted to the hospital for hip pain related to an injury of unknown origin, and there was no bed-hold notice provided to the resident or representative for that transfer. Additional residents were similarly affected. One resident (R7) was transferred to the hospital for change in condition on two separate occasions and did not receive a notice of bed-hold indicating reserve payment or a notice before transfer/discharge stating the specific reason for the transfer/discharge. Two cognitively intact residents (R2 and R14), each scoring 15/15 on BIMS, had bed-hold forms signed by care managers from managed care organizations indicating they wished to reserve their rooms; however, R2’s bed-hold notice did not include the daily rate for reservation, and R14 did not receive a bed-hold notice for a subsequent hospital transfer. During the survey, the social worker responsible for transfers was unavailable due to illness, and the assistant nursing home administrator reported not being aware of the transfer/discharge process and needed to consult the nursing home administrator, but no follow-up was provided by survey exit.
Failure to Protect a Resident From Misappropriation of Personal Property and to Conduct Required Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to follow its abuse and misappropriation investigation and reporting policies. On 01/07/26, the facility was made aware that a resident (R29) was missing multiple personal items, including a cell phone, cell phone charger, wallet containing $80.00, tennis shoes, two grabbers, and a wicker/wooden box with household items such as keys. The facility’s own policies stated that residents have the right to be free from misappropriation of property and that all reports of misappropriation must be promptly reported to local, state, and federal agencies and thoroughly investigated. Despite this, the facility did not protect the resident from misappropriation, did not report the allegation to the State Agency, and did not begin an investigation until 01/09/26. When the surveyor reviewed a complaint submitted to the State Agency by the resident’s family member on 01/08/26, the family member confirmed the list of missing items and stated she had filed two grievances with the facility and also reported the incident to law enforcement. Review of the facility’s grievance log for the prior three months showed only one grievance for this resident, dated 10/06/25, unrelated to missing property, and the facility did not provide its grievance policy when requested. Over several days, the surveyor repeatedly requested the facility’s internal investigation of the missing property; the facility did not provide any investigation documentation until 01/13/26, at which time only a single Grievance/Complaint form dated 01/07/26 was produced. That form showed the grievance was assigned on 01/09/26 and documented that staff searched the resident’s room and laundry and were waiting for the daughter to call back to make a plan to replace items. The facility was unable to locate the missing property and did not provide any additional information indicating that required interviews or a thorough investigation had been conducted.
Failure to Thoroughly Investigate Missing Property and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into allegations of abuse and misappropriation of resident property for two residents. For one resident, the facility was notified that personal property, including $80 in cash, was missing. Although the grievance was reportedly filed by the family member, the facility did not begin its investigation until two days after being made aware of the missing items. The only documented investigative action was a grievance/complaint form indicating that staff searched the resident’s room and laundry, waited a couple of days, rechecked laundry, and then contacted the resident’s daughter about replacing the items. No documentation was provided to show that staff or other residents were interviewed, and the facility was unable to locate the missing property. The surveyor requested the facility’s internal investigation multiple times over several days and was only provided the single grievance form, with no additional investigative documentation. For the second resident, the deficiency centers on the facility’s incomplete investigation into a pelvic fracture of unknown origin. This resident had a history of falls and multiple fall-related care plan interventions, and had moderate cognitive impairment as evidenced by a BIMS score of 9/15. On the morning in question, the resident began to complain of pain but initially denied falling. A progress note, lacking date, time, and author, documented that the resident complained of left hip pain, denied any falls during the night, was given acetaminophen, and that an x-ray was ordered. Due to weather-related delays with mobile x-ray, the resident was sent to the ER, where imaging revealed a markedly comminuted fracture of the left acetabulum and a nondisplaced fracture of the left inferior pubic ramus, with associated hemorrhage. The facility’s investigation into the resident’s injury did not meet its own policy requirements for a thorough abuse or injury-of-unknown-source investigation. The investigation worksheet identified two staff members, an LPN and a CNA, as involved or potential witnesses, and only these two staff were interviewed. The LPN reported finding the resident partially off the bed and assisting the resident back to bed without signs of pain, and the CNA reported responding to the resident’s calls during the night, noting restlessness but no complaints and that the resident was asleep when the Foley catheter was emptied. The worksheet documented that no interview was conducted with the resident by facility staff, that a complete physical and emotional assessment identifying areas of injury was not completed, and that there were no new interventions or clear conclusions about how or why the incident occurred. It also noted that documentation in the resident record was not complete and left sections regarding root cause, care plan revisions, and other corrective actions unanswered. The nursing home administrator confirmed that the paperwork submitted to the state constituted the entirety of the 5-day investigation and that no additional investigation was performed. Across both examples, the facility’s actions did not align with its written policies on abuse prevention and abuse investigation and reporting, which require prompt reporting, thorough investigation, and interviews with the resident, the reporter, witnesses, and staff on all shifts who had contact with the resident during the relevant period. In the case of the missing property, the facility did not document interviews or a comprehensive inquiry into the alleged misappropriation. In the case of the pelvic fracture, the facility did not complete a full assessment, did not interview the resident, did not identify a root cause, and did not fully document the incident in the medical record, resulting in an incomplete investigation of a serious injury of unknown source and failure to rule out abuse as required by policy.
Failure to Follow Wound Care and Blood Pressure Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide wound care and monitoring according to professional standards for two residents. One resident with chronic osteomyelitis, bilateral foot ulcers with necrosis of bone, toe amputations, diabetes, and sepsis was admitted with active treatment orders on the TAR for nightly and as-needed dressing changes to bilateral lower extremities, including monitoring for infection, documenting drainage, and documenting pain scores. The resident’s initial care plan did not address wounds or wound care interventions. Surveyor review of the TAR showed no documentation of daily assessments or dressing changes from 1/5/26 to 1/10/26, despite the active orders. When observed, the resident’s foot dressings were loosely wrapped, and the resident reported having wounds on both feet and not believing dressing changes had been done since admission. An LPN stated the dressing changes were done as needed and would be documented in the TAR, but the TAR lacked entries for the specified dates. The DON confirmed that the TAR orders required daily dressing changes and that documentation only showed dressing changes on 1/11 and 1/12/26, indicating the dressings were not changed on 1/5 through 1/10/26. The second resident, with hypertension, chronic kidney disease, and cognitive decline, experienced a fall from a recliner and was found on the floor, incontinent but alert and oriented, with vital signs stable except for low blood pressure. The nurse documented that the NP was notified and instructed staff to push fluids and assess blood pressure every hour to determine if hospital transfer was needed, and to hold all blood pressure medications until blood pressure reached proper levels. The MAR showed antihypertensive medications were held on the day of the incident, and all medications were administered as ordered on the following two days, including the morning of 12/23/25. However, surveyor review could not locate documentation of blood pressure readings after the initial incident, nor documentation that medications were held as ordered beyond what appeared on the MAR. The DON stated she was unable to find documentation that nursing staff followed the NP’s orders to monitor blood pressure until it reached acceptable levels or that medications were held as directed.
Failure to Maintain Elopement Protection and Safe Transfer Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistive devices for two residents. One resident with anxiety, depression, dementia, and severe cognitive impairment (BIMS 5/15) had been assessed as an elopement risk and care planned to wear a wanderguard on the left wrist, with orders and TAR documentation indicating staff were to check the device’s placement, function, and the skin around it every shift. The elopement assessment, care plan, and elopement binder all identified this resident as an elopement risk with a wanderguard in place. However, during surveyor observations and interviews on the same day, the resident was repeatedly observed without a wanderguard on the left wrist, left ankle, body, or wheelchair. Despite this, nursing documentation reflected that the wanderguard was being checked, and staff interviews showed uncertainty about whether the resident had a wanderguard on, with one CNA reporting that when taking the resident outside to smoke, no alarm had ever sounded. The second example concerns a resident with moderately impaired cognition (BIMS 5) who required substantial/maximal assistance for toilet transfers and had a care plan specifying a two‑person transfer with a gait belt. A surveyor observed this resident sitting on the toilet under the supervision of a CNA, with no gait belt in place. The CNA then performed incontinence care and transferred the resident independently to a wheelchair without using a gait belt. When questioned, the CNA stated that they had not been using a gait belt for this resident’s transfers and, after checking the care plan, stated that it did not indicate the need for a gait belt, despite the documented care plan approach requiring one.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted and updated, including the total number of hours and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, potentially affecting all 47 residents in the facility. On entrance to the facility, the surveyor observed that the Direct Care Report posted in the lobby was dated several weeks earlier and reflected a census of 47, indicating it was not current. Subsequent review of staff schedules and staff postings from early December through mid-January showed that schedules had multiple marked changes on specific dates, but the corresponding daily staff postings did not reflect accurate staffing numbers for several of those days. During an interview, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing information in the morning after updating the census, and that the daily posting is not manually updated when staffing changes occur, with changes only reflected on the internal daily schedules rather than on the publicly posted staffing information. No specific residents, medical histories, or clinical conditions were described in the report beyond the total facility census of 47 residents who could be affected by the inaccurate staffing postings.
Failure to Follow Hospital Discharge Wound Care Orders and Consult Physician
Penalty
Summary
A deficiency occurred when the facility failed to consult with a physician and follow hospital discharge instructions regarding wound care for a resident admitted after hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene. The resident, who had moderately impaired cognition, was discharged from the hospital with orders for a wound VAC (vacuum assisted closure) and vancomycin solution irrigation to be applied to a large right groin wound. Upon admission, these orders were not properly communicated or implemented by facility staff. Facility records and staff interviews revealed that the wound VAC and vancomycin solution were not available or administered as ordered. The admitting nurse, who was from an agency, did not ensure the wound care orders were entered or followed. Other nursing staff were unaware of the specific wound care requirements until several days after admission, and the vancomycin solution was never ordered. The wound VAC was not ordered until staff discovered documentation in the resident's room, and it was delivered two days after admission. During this period, the resident did not receive the prescribed wound care, and documentation of wound care was missing for several shifts. When the wound VAC was finally to be applied, staff discovered the resident's wound was contaminated with stool, and the resident was experiencing significant pain. The physician determined that the wound VAC had not been applied as intended and that the wound was at risk due to contamination. The resident was subsequently sent to the emergency room for wound care. Interviews with staff and review of records confirmed that the facility did not consult with a physician when unable to obtain the necessary wound care supplies and did not follow the hospital's discharge instructions for wound management.
Failure to Develop Baseline Wound Care Plan Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan for wound care within 48 hours of admission for a resident who was admitted following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin. The resident had a history of multiple debridements, extensive antibiotic therapy, and required a Foley catheter to maintain wound cleanliness. Upon discharge from the hospital, the resident had specific wound care orders, including the initiation of a wound VAC and vancomycin irrigation, as well as ongoing antibiotic therapy. Despite these complex medical needs and clear physician orders for wound care, the facility's care plan for the resident only included documentation for a Foley catheter and advanced directives, with no baseline care plan addressing wound care. This omission was confirmed during an interview with an LPN, who acknowledged that a baseline care plan for wound care had not been developed for the resident.
Failure to Provide Ordered Wound Care and Timely Wound VAC Application
Penalty
Summary
A resident was admitted to the facility following hospitalization for sepsis related to necrotizing fasciitis and Fournier's gangrene of the right groin, with a significant wound requiring specialized care. Upon admission, the resident had physician orders for wound care, including the use of a wound VAC and vancomycin solution irrigation, as well as a Foley catheter to maintain cleanliness. However, the facility failed to implement a baseline care plan addressing the resident's wounds, and the wound care orders were not accurately or promptly entered into the treatment administration record (TAR). The only wound care documented was a single wet-to-dry dressing change, and there was no evidence that the vancomycin solution was ordered or administered as prescribed. The facility did not ensure the timely provision of a wound VAC, which was specifically ordered to prevent contamination of the wound with stool due to its location and severity. The wound VAC was not ordered until several days after admission, and it did not arrive until the morning the resident was sent back to the hospital. During this period, the resident's wound was left exposed and ultimately became contaminated with stool, as documented by both a physician assistant and a physician who assessed the resident. The lack of appropriate wound care and delay in obtaining the wound VAC resulted in the resident experiencing significant pain and required transfer back to the hospital for further treatment. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's wound care needs and orders. The admitting nurse was from an agency and could not be interviewed, while other nursing staff were unaware of the specific wound care orders until documentation was found in the resident's room. The facility's documentation and assessment of the wound were also inaccurate, misclassifying the wound type and failing to measure it upon admission. No additional evidence was provided to support that the resident received the ordered care during the period in question.
Failure to Appoint RN as Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis, as required by federal regulations. Instead, the DON position was filled by an LPN, and there was a period when the facility had no DON at all. This was confirmed through interviews with the Assistant Nursing Home Administrator and the Assistant Director of Nursing, both of whom stated that after the previous DON, who was an RN, resigned, there was a gap before the LPN was hired as DON. During this time, the ADON, also an LPN, was the only nursing leadership present. The surveyor reviewed multiple complaint investigations and the facility's grievance log during the period when the LPN was serving as DON. Several complaint investigations resulted in citations related to pharmacy services, food procurement, catheter care, bedhold, notice of transfer, Ombudsman notification, CPR, intravenous fluids, medication errors, and quality assurance activities. The grievance log showed a notable number of grievances filed during the months when the LPN was acting as DON, indicating ongoing concerns during this period.
Failure to Timely Request and Support Waiver for RN DON Requirement
Penalty
Summary
The facility failed to request a waiver in a timely and complete manner when unable to meet the requirement of having a registered nurse serve as the Director of Nursing (DON). After the resignation of the previous DON, who was a registered nurse, the facility was without a registered nurse in this position for an extended period. Although the facility eventually submitted a waiver request, it did so several months after the vacancy began. The State Agency (SA) denied the initial waiver request and requested additional information to demonstrate diligent efforts to recruit appropriate personnel, evidence that a waiver would not endanger resident health or safety, and confirmation that a registered nurse or physician was available to respond to calls when licensed nursing services were unavailable. The facility did not respond to the SA's request for further information, nor did it submit an additional waiver request as instructed. During an on-site investigation, it was confirmed that the acting DON was not a registered nurse and did not meet state and federal requirements.
Call Light System Failure Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call light system was fully operational in all resident areas, including bathrooms and bathing areas. Observations revealed that call lights on all resident halls were activated but not sounding, and the system at the nurse's station was not alerting staff when call lights were activated. Multiple interviews with residents, family members, and staff confirmed that the auditory alarms had not been functioning for approximately five weeks, and that staff were not being notified of call lights at the nurse's station. Residents reported long wait times for assistance, sometimes up to an hour, and family members observed staff taking up to 40 minutes to respond to call lights. Some residents had to leave their rooms and call out in the hallway to get help. The Assistant Director of Nursing and the Assistant Nursing Home Administrator both confirmed the lack of auditory alerts, with the latter stating that she was told the system was considered functional as long as the lights worked. Maintenance staff reported ongoing issues with obtaining replacement parts for the outdated system, with several unsuccessful attempts to repair it using refurbished components. Documentation provided included invoices and delivery records for replacement parts, and the facility's grievance log showed five complaints related to call lights in the previous month.
Delay in Initiating CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to ensure that cardiopulmonary resuscitation (CPR) was provided immediately when a resident was found unresponsive. The resident, who had diagnoses including gram-positive bacteremia, Parkinson's disease, seizure disorder, and difficulty walking, was documented as a full code in both physician orders and the care plan, indicating that all life-saving measures, including CPR, should be performed in the event of cardiac or respiratory arrest. The care plan specifically stated that the resident's code status should be honored and that CPR should be initiated in the event of a code. On the day of the incident, a CNA discovered the resident unresponsive, face down, and not breathing, with no visible or audible signs of life. The CNA did not call for help from within the room but instead left to find a nurse. The LPN who responded also found the resident unresponsive and without a pulse, and instructed the CNA to get the RN and to call 911. CPR was not initiated until the RN arrived and, with assistance, repositioned the resident to the floor. The RN then began chest compressions, and the LPN provided breaths with an Ambu bag. The delay in starting CPR was confirmed by interviews and documentation, as CPR was not started until after the RN entered the room and the resident was repositioned. Facility policy required that staff check for responsiveness, breathing, and pulse, call for help, activate emergency response, and start CPR immediately if no pulse or breathing was detected. Interviews with facility leadership confirmed that the expectation was for CPR to be started as soon as possible, in accordance with policy and the resident's full code status. The delay in initiating CPR was contrary to these expectations and the facility's written procedures.
Failure to Document and Order PICC Line Care for IV Administration
Penalty
Summary
A resident with a history of gram-positive bacteremia and moderately impaired cognition was admitted to the facility with a peripherally inserted central catheter (PICC) line for IV antibiotic administration. The resident's hospital discharge summary indicated the PICC line was placed prior to transfer, and IV antibiotics were administered through this line. However, review of the clinical physician orders, medication administration records (MARs), and treatment administration records (TARs) revealed there were no documented orders or records for routine PICC line care, including site monitoring, flushing to maintain patency, or dressing changes. Progress notes also lacked documentation of these essential PICC line care activities. Staff interviews confirmed that there were no standing orders for PICC line care on the resident's records, and the facility's policy required physician orders for IV fluids and site monitoring. The resident ultimately experienced a PICC line occlusion, resulting in a transfer to the emergency room, where the line could not be unclogged and was replaced with a midline catheter. The absence of documented orders and care for the PICC line constituted a failure to provide safe and appropriate administration of IV fluids and line maintenance.
Failure to Administer Medications at Prescribed Times
Penalty
Summary
The facility failed to administer medications as scheduled for two of five residents reviewed for pharmacy services. For one resident with severe cognitive impairment and multiple diagnoses, including generalized anxiety disorder and neurocognitive disorder, medication administration records showed that clonazepam and baclofen were not given at the prescribed times. Doses were administered several hours late or too close together, with some doses given less than an hour apart, contrary to the scheduled intervals. Observations confirmed that medications were administered outside the prescribed timeframes. Another resident, who was cognitively intact and had diagnoses of mood disorder and major depressive disorder, also did not receive medications as scheduled. Buspirone and gabapentin, both ordered three times daily, were administered hours late or with insufficient intervals between doses. Medication administration records and direct observation documented these timing discrepancies. Interviews with staff revealed a lack of consistent understanding and adherence to medication administration timing policies. A certified medication aide stated that medications could be given within a one-hour window of the scheduled time, but did not check the last administration time for medications given multiple times a day. The assistant director of nursing and director of nursing described a more liberalized approach to medication timing, but were unclear on procedures for medications scheduled more than once daily. Facility policy required medications to be administered within one hour of the prescribed time, unless otherwise specified, but this was not followed.
Missed Doses of IV Antibiotic Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that Vancomycin, an IV antibiotic, was administered as ordered for a resident diagnosed with gram-positive bacteremia. The resident was admitted with a history of receiving IV antibiotics in the hospital, and the discharge orders specified daily Vancomycin administration. Upon admission, the facility received an order to start Vancomycin on a specific date and time, but the medication was not available in the facility for two consecutive days. Documentation showed that the pharmacy was contacted and the order was refaxed, with the pharmacy indicating the medication would be delivered that night, but the first dose was not administered until two days after the scheduled start date. The electronic Medication Administration Record (eMAR) and progress notes confirmed that Vancomycin was not administered on the first two scheduled days, and the first dose was given on the third day. The nurse practitioner responsible for the resident was not informed of the missed doses and stated that he would have taken additional steps if he had been notified. The facility's policy required medications to be administered in a safe and timely manner, within one hour of the prescribed time unless otherwise specified, but this was not followed in this instance.
Failure to Investigate and Review Adverse Event Resulting in Resident Death
Penalty
Summary
The facility failed to identify and investigate an adverse event involving a resident who was found unresponsive with her chin and neck pressed against the bed frame, her lower body on the floor, and required CPR according to her code status. The resident had a history of Parkinson's disease, seizure disorder or epilepsy, difficulty walking, and moderately impaired cognition. Staff interviews revealed that the resident was discovered in a face-down, back-bending position, and was unresponsive with no pulse or breathing detected. Despite the circumstances, no incident report was created for this event, and there was no evidence of a Quality Assurance and Performance Improvement (QAPI) review or internal investigation by the facility's Quality Assessment and Assurance (QAA) committee. The facility's policies required the QAA committee to oversee the identification and handling of quality issues, including adverse events and negative outcomes related to resident care and safety. However, the committee did not identify the resident's death as an adverse event, did not initiate an incident report, and did not review or investigate the incident. The Regional Support Administrator acknowledged that a death from an injury of unknown origin should be considered an adverse event and reviewed by the QAA committee, but confirmed that this did not occur in this case.
Failure to Monitor and Document Catheter Output and Assess for Complications
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for residents with indwelling Foley and suprapubic catheters, resulting in inadequate monitoring and documentation of urinary output, as well as insufficient assessment and provider notification when abnormal findings were present. For three residents with catheters, there were repeated instances where urine output was either not documented, documented as zero without further assessment, or recorded with unclear or missing amounts. In multiple cases, there was no evidence that the provider was notified when urine output was absent for a shift, as required by physician orders and facility policy. One resident with a suprapubic catheter experienced two days of increased incontinence and lack of catheter drainage, which was not properly assessed or reported. The resident was ultimately transferred to the hospital and admitted with a severe urinary tract infection. Review of the medical record showed multiple shifts with zero urine output documented and no corresponding provider notification or additional nursing assessments, such as checking catheter patency, vital signs, or abdominal assessment. Interviews with nursing staff revealed a lack of clear parameters for when to notify providers and inconsistent understanding of required assessments when abnormal output was noted. For two other residents with indwelling catheters, similar deficiencies were observed. Documentation of urinary output was frequently missing, incomplete, or unclear, and there was no evidence of provider notification or further assessment when output was zero or not recorded. Facility policies and professional standards require accurate monitoring and reporting of catheter output to prevent complications, but these were not consistently followed, as evidenced by the surveyor's review of records and staff interviews.
Failure to Provide Required Transfer Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers for three residents. Specifically, when residents experienced a change in condition and were transferred to the hospital, the facility did not provide a Notice of Bedhold or a written Notice of Transfer to the residents or their representatives. Additionally, there was no documentation that the Ombudsman was notified of these transfers. This deficiency was identified through record review and interviews, which confirmed the absence of these required notifications for all three residents involved. One resident with an activated Power of Attorney was transferred to the hospital on two separate occasions following falls, but neither a Bedhold notice nor a Notice of Transfer was provided to the representative, and the Ombudsman was not notified. Another resident with a legal guardian was transferred to the hospital without the required notifications being given. A third resident, who was her own decision maker and had diagnoses of multiple sclerosis and neurogenic bladder, was also transferred to the hospital without documentation of a Bedhold notice, written transfer notice, or Ombudsman notification. The Nursing Home Administrator confirmed that these notifications were not provided and was unaware of the requirements for issuing them at the time of each transfer.
Improper Storage and Labeling of Medications and Supplies
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were properly stored and labeled according to professional standards. In the medication storage room, a bottle of lorazepam prescribed to a resident was found in an unlocked refrigerator, despite being labeled as opened on 12/01/24 and identified as expired by the Director of Nursing (DON). Additionally, two open bottles of eye drops were found in a larger refrigerator without proper labeling or open dates, with only 'AM' and 'PM' written on the sides. The DON acknowledged that these medications should have been labeled. Further inspection of the medication storage room revealed four opened boxes of intermittent catheters, three of which had expiration dates of 05/31/2020 and one with 07/05/2020. The DON confirmed these supplies were expired and should not have been stored in the cabinet. Interviews with staff, including a Certified Medication Aide (CMA) and an LPN, demonstrated a lack of knowledge regarding the identification of expired supplies and the proper storage of medications, including the requirement for locked storage and appropriate labeling.
Failure to Monitor and Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure continued monitoring of internal food temperatures as required by its policy, which states that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, with temperatures properly recorded prior to each meal service. During observation, kitchen staff loaded and served trays to residents in two hallways, with the last tray served containing over-easy eggs measured at 107.2 degrees Fahrenheit, well below the required temperature. The eggs were placed on the tray directly from the grill without an internal temperature check, and staff were unaware of the eggs' temperature prior to service. Resident council meeting minutes previously indicated concerns with food being served late, and while food logs showed temperatures taken at the beginning and end of service, there was no evidence of temperature monitoring during the meal service. The resident who received the eggs had no complaints and consumed the meal.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for two of four sampled residents. In one case, a resident admitted after hip surgery with multiple diagnoses, including high cholesterol, coronary artery disease, parkinsonism, and cognitive impairment, had a physician order for Aspirin 81mg twice daily to prevent clotting. However, the medication order was incorrectly transcribed into the electronic Medication Administration Record (eMAR) as 81mg once daily, resulting in the resident not receiving the prescribed dose for several weeks after admission. The error was only corrected weeks later, and the resident did not receive the correct dosing until that time. In another instance, a resident with paralysis, nerve pain, osteoarthritis, hypertension, and high cholesterol, who was dependent for mobility and activities of daily living, did not receive prescribed evening medications (Carbamazepine and Famotidine) on two separate occasions. The eMAR showed no documentation of medication administration, refusal, or the resident being out of the facility, and the required codes or progress notes were absent. Staff interviews confirmed that the medications were not administered and that the expected documentation was not completed.
Failure to Notify Provider of Positive Urinalysis Results
Penalty
Summary
The facility failed to ensure that a physician was notified of laboratory results for a resident who had a history of urinary tract infections, renal insufficiency, and chronic suprapubic catheter use. The resident was admitted with multiple urological issues and had recently undergone stent placement due to kidney stones. A urinalysis was ordered by the resident's urologist as part of pre-surgical planning for stent removal, and the urine specimen was collected and sent to the lab as ordered. When the urinalysis results were received, they showed significant growth of pathogens, specifically klebsiella variicola and proteus mirabilis. However, the facility did not update either the resident's primary provider or the urologist with these results. The order for the urinalysis was incorrectly placed under the facility's medical director rather than the urologist who had requested it, resulting in a lack of follow-up. Both the nurse practitioner and the urologist confirmed they were not made aware of the results, and the infection preventionist stated that a provider should have been updated with the results regardless of whether they were positive or negative. Four days after the urinalysis results were available, the resident experienced a change in condition, including dizziness, lethargy, and fever, and was subsequently hospitalized for sepsis. The discharge summary from the hospital indicated the resident was treated for septicemia, with possible sources including a catheter-associated urinary tract infection and pneumonia. Interviews with facility staff confirmed that the resident had no symptoms prior to the acute event, and the lack of provider notification regarding the urinalysis results was not explained by facility staff.
Failure to Update Facility Assessment and Staffing Levels
Penalty
Summary
The facility failed to update its facility-wide assessment to reflect the current resident care needs and the resources required to support these needs. The assessment, last revised on 01/01/25, did not account for a significant increase in resident census from the mid-30s to 48 residents, following 18 new admissions over a 21-day period. The staffing ratios outlined in the assessment were based on the previous census and did not accommodate the increased number of residents, leading to insufficient staffing levels. Interviews with staff, including CNAs and RNs, revealed that the rapid increase in admissions was not matched by an increase in staffing, resulting in each CNA being responsible for 16 to 18 residents during the day and over 20 at night. This staffing shortage made it difficult to safely care for residents, as CNAs often had to assist with two-person transfers, leaving other residents unattended. Scheduled showers were postponed, and staff reported resignations due to the stress of the increased workload and lack of administrative response to requests for additional help. RNs also reported challenges in managing the increased workload, with responsibilities including medication administration, treatments, assessments, and new resident admissions. The delay in medication, treatment, and assessment completion was noted, and staff expressed concerns about missing changes in residents' conditions due to time constraints. The Nursing Home Administrator acknowledged that the facility assessment had not been updated to reflect the increased census and staffing needs, indicating a lack of proactive planning in response to the facility's efforts to increase its resident population.
Failure to Provide Comprehensive Care Leads to Hospitalizations
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice and the residents' comprehensive person-centered care plans for two residents. Resident R21, who had a history of congestive heart failure (CHF) and other cardiac conditions, did not receive comprehensive CHF assessments or necessary lab tests to monitor their condition. Despite showing symptoms of shortness of breath and nausea, the facility did not complete the ordered Basic Metabolic Panel (BMP) and B-type Natriuretic Peptide (BNP) tests. This oversight led to R21 being hospitalized with an exacerbation of CHF and a Non-ST segment elevation myocardial infarction. Resident R6, who had multiple non-pressure wounds, did not receive timely and comprehensive skin assessments. The facility failed to conduct a comprehensive skin assessment upon R6's admission and did not perform weekly assessments as required. Additionally, R6 missed wound care appointments, and there was no evidence of follow-up or communication with the wound care clinic regarding missed appointments or changes in R6's condition. This lack of proper wound care management contributed to R6's hospitalization and subsequent amputation due to necrotic wounds. Interviews with facility staff, including the Director of Nursing (DON) and Registered Nurses (RNs), revealed a lack of adherence to the facility's policies and procedures for monitoring and documenting residents' conditions. The DON acknowledged the absence of comprehensive assessments and the failure to notify providers of changes in residents' conditions. The facility's inability to ensure proper care and treatment for residents R21 and R6 resulted in actual harm, as evidenced by their hospitalizations and deteriorating health conditions.
Improper Food Handling and Sanitization Practices
Penalty
Summary
The facility failed to ensure proper sanitization and food handling practices, which could potentially lead to foodborne illnesses among all 28 residents. Observations revealed that serving utensils were improperly stored in thickener powder, and cooks were seen handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. Additionally, cooks did not perform hand hygiene between glove changes during food service, and hair restraints were not worn correctly by staff entering the kitchen, preparing, or serving food. Further observations indicated that food items, such as milk, were placed in the kitchen refrigerator without being labeled with an opened date, increasing the risk of foodborne illnesses. The facility's policy on preventing foodborne illness was not adhered to, as employees failed to wash their hands before handling food, after touching soiled equipment, and during food preparation. The use of gloves was not managed properly, as they were not changed after contamination, and hand hygiene was not performed before putting on new gloves. The facility's refrigerator and freezer contained several unlabeled and undated food items, including leftovers and opened food containers, which were not monitored or discarded as per the facility's policy. Interviews with staff, including the Nursing Home Administrator and Director of Nursing, confirmed that the expectation was for all food items to be labeled and dated, and for kitchen staff to routinely monitor and discard undated or expired items. However, these practices were not consistently followed, leading to the observed deficiencies.
Failure to Notify Physician of Resident's Transfer to ED
Penalty
Summary
The facility failed to immediately notify a resident's physician when the resident experienced difficulty breathing and was transferred to the Emergency Department (ED) via Emergency Medical Services (EMS). This deficiency was identified for a resident who had been admitted with multiple diagnoses, including congestive heart failure and myocardial infarction. The resident had been experiencing shortness of breath for several days before being sent to the hospital in the middle of the night. Upon review, it was found that there was no documentation indicating that the resident's physician was informed of the transfer to the ED. The Nurse Practitioner (NP) was not notified of the resident's condition and transfer until the following day, which led to the resident's admission to the hospital. The Director of Nursing (DON) confirmed that there was no notification to any providers about the resident's change in condition and transfer, which was against the expected standard practice of notifying the physician within 15-30 minutes of a change in condition.
Failure to Conduct PASRR Level II Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to conduct a Preadmission Screening Resident Review (PASRR) Level II screen for a resident with a serious mental disorder who was taking psychotropic medication. This oversight was identified during a review of the resident's records and an interview with the Nursing Home Administrator. The resident, who was admitted with a diagnosis of schizoaffective disorder, was prescribed medications including Haldol, ziprasidone, and sertraline. A Level I PASRR screening indicated the need for a Level II screening due to the resident's major mental disorder and use of psychotropic medications. Despite the completion of form F-20822, which recommended nursing facility placement with a short-term exemption from a Level II screening, no specific short-term exemption option was selected. The form also noted that if the resident required nursing facility placement beyond the permitted timeframes of the short-term exemptions, a Level II screening was necessary. However, the surveyor could not locate a completed Level II PASRR screening in the resident's records, and the Nursing Home Administrator confirmed that it had not been completed.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident, identified as R21, who was at risk for pressure injuries and had existing pressure injuries upon admission. The facility did not apply the prescribed purple boots for off-loading heels as ordered, and comprehensive skin assessments were not conducted consistently. The resident was admitted with seven pressure injuries, but the facility did not document their locations, sizes, or stages, making it unclear whether any of the injuries progressed or were already at advanced stages upon admission. The resident's care plan included the use of purple heel protector boots at all times, but observations on multiple occasions showed that the resident was not wearing the boots while sitting in a wheelchair. Staff interviews revealed inconsistencies in applying the boots and documenting their application. The Director of Nursing acknowledged that staff had not been consistent in applying the boots, and a Certified Nurse Assistant admitted to not re-approaching the resident after an initial refusal to wear the boots. The facility also failed to conduct thorough pressure injury assessments, including documentation of the location, measurements, and condition of the injuries. The wound clinic notes indicated a lack of detailed assessments, and the facility did not complete pressure injury assessments from admission until July 1st. The surveyor was unable to determine the progression of the injuries due to the lack of documentation and numbering of the pressure injuries by the wound clinic and the facility.
Failure to Implement Resident's Ambulation Program
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's mobility, specifically for a resident identified as R10. The facility lacked a maintenance or restorative program, as confirmed by the Director of Nursing (DON), which contributed to the deficiency. R10's care plan included a recommendation for ambulation to maintain the current level of function and minimize fall risk, yet the staff did not implement this program. Observations by the surveyor showed that R10 was transported in a wheelchair to and from meals without being offered the opportunity to ambulate, contrary to the care plan instructions. R10's medical history includes frontotemporal dementia with agitation, COPD, anemia, depression with anxiety, CHF, tremors, subarachnoid hemorrhage, seizures, and incontinence. Despite these conditions, R10 was noted to have no range of motion impairments and required supervision with transfers. The surveyor found no evidence in R10's records that the walking program was conducted, and the DON confirmed that the program was not offered from July 1, 2024, to the present. A CNA caring for R10 indicated that she had not discussed the ambulation program with nursing or therapy staff, highlighting a communication gap regarding R10's care needs.
Failure to Assess Indwelling Catheter Removal
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter was assessed for its removal as soon as possible, as required by their policy. The resident, who was admitted with an indwelling catheter, had diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, urinary tract infection, and overactive bladder. Despite these conditions, the facility did not attempt a urinary toileting program or assess urinary continence due to the presence of the catheter. The facility's policy mandates that residents with indwelling catheters be assessed for removal upon admission, quarterly, and with any change in condition, but this was not done for the resident in question. The Director of Nursing (DON) acknowledged that the routine changing of catheters, as practiced by the facility, did not align with current standards of practice or the facility's policy, which recommends changing catheters based on clinical indications rather than at fixed intervals. The resident's care plan included a diagnosis of neurogenic bladder, which was not supported by documentation, and the catheter was changed every four weeks as per physician orders. The facility failed to provide additional documentation, such as urology visits or orders, to justify the continued use of the indwelling catheter, and the DON admitted that the resident's diagnoses did not meet the criteria for its use.
Infection Control Deficiencies in PPE Usage and Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving residents. In the first instance, a resident with an indwelling catheter was under Enhanced Barrier Precautions (EBP), which required staff to wear gowns and gloves during high-contact care activities. However, a Certified Nursing Assistant (CNA) was observed not wearing a protective gown while performing a task related to the resident's catheter care. The CNA acknowledged the expectation to wear appropriate Personal Protective Equipment (PPE) but admitted to skipping it to expedite the task. The Director of Nursing confirmed that staff are expected to adhere to facility policies to prevent infections. In the second instance, a resident tested positive for COVID-19 and was supposed to be under droplet precautions. However, there was no appropriate signage on the resident's door to indicate the need for specific PPE, and an Enhanced Barrier Precaution sign was incorrectly placed on the PPE cart. A CNA was unaware of the correct precautions and had to consult a Registered Nurse (RN), who then acknowledged the oversight and corrected the signage. The RN admitted that staff likely entered the resident's room without proper PPE from the time the resident tested positive until the signage was corrected, potentially exposing themselves to the virus.
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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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