Ccc Of West Green Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Bay, Wisconsin.
- Location
- 1760 Shawano Ave, Green Bay, Wisconsin 54303
- CMS Provider Number
- 525232
- Inspections on file
- 27
- Latest survey
- January 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ccc Of West Green Bay during CMS and state inspections, most recent first.
A facility failed to thoroughly investigate an incident where a resident kicked another resident in the hallway. Despite the facility's policy requiring a comprehensive investigation, the involved resident was not interviewed, and no other staff interviews were conducted. The care plan of the aggressive resident, who had severe cognitive impairment, was not updated to include interventions for monitoring behaviors related to resident-to-resident altercations.
The facility failed to provide written transfer or discharge notices to two residents. One resident was discharged to a community-based residential facility, and another was transferred to the hospital with sepsis, both without receiving the required notices. The Nursing Home Administrator confirmed the lack of documentation, and the facility did not have a policy for transfer/discharge notices.
The facility failed to provide written bed hold notices to two residents upon their transfer to a hospital, as required by policy. One resident was transferred with sepsis, and another due to critical lab results, but neither received the necessary documentation. The Nursing Home Administrator confirmed the lack of documentation for these notifications.
The facility did not maintain an effective infection prevention and control program during a COVID-19 outbreak. Three housekeeping staff members were not provided with appropriate education and PPE prior to and during the outbreak. Two housekeepers were not fit-tested for N95 masks until 11 days after the outbreak began, and they worked multiple shifts in COVID-19 positive areas without the necessary PPE. Interviews confirmed the absence of documented infection control training for these employees prior to the outbreak.
The facility failed to provide proper catheter care and documentation for two residents, leading to deficiencies in measuring output and preventing UTIs. One resident's catheter tubing was not held at the meatus during care, and output was not documented per policy, with records showing improper maintenance. The second resident's catheter output was not emptied or documented as required, with staff confirming that catheter bags should be emptied every shift but were not consistently done.
A resident with a history of dysphagia and impaired cognition was not provided with a recommended and ordered video swallow study to assess swallowing difficulties. Despite a physician's order and the facility's policy requiring confirmation and completion of such orders, the study was not scheduled or completed. The resident was later hospitalized with acute hypoxic respiratory failure, potentially linked to recurrent aspiration pneumonia. Facility staff confirmed the order was in the medical record but could not explain the oversight.
The facility failed to provide scheduled showers and baths for three residents, as required by their policy. One resident reported not receiving a shower since before Christmas, leading to skin issues. Another resident did not receive weekly showers during their stay, and a third resident had to request washcloths to clean themselves. Staff cited staffing shortages as a reason for not completing showers, and documentation was often missing or falsified.
A resident with moderate cognitive impairment and multiple diagnoses sustained several skin injuries without proper assessment or notification to their physician or POAHC. The facility's policy required weekly skin assessments and documentation, which were not completed, leading to unreported skin tears on the resident's elbow and knees. The DON confirmed the oversight, and the POAHC expressed concern over the lack of communication.
A resident with moderate cognitive impairment experienced three unwitnessed falls at the facility. Despite the facility's policy requiring neurological assessments after falls, staff did not complete the required neurochecks for two of the falls. The facility's policy mandates specific intervals for neurochecks, but these were not adhered to, as confirmed by interviews with the RN and DON. The resident's medical history included conditions necessitating careful monitoring, highlighting a deficiency in care standards.
A resident in the facility experienced discrepancies in the administration and documentation of lorazepam, a psychotropic medication. The facility's records showed inconsistencies between the Controlled Drug Record/Disposition Form and the Medication Administration Record (MAR), with doses not aligning with physician orders. Staff interviews confirmed these discrepancies, highlighting a failure to adhere to medication administration policies.
A resident's guardian was not informed of a significant change in the resident's clonazepam dosage, leading to increased anxiety and a request to revert to the original dosage. The facility's staff failed to communicate the change, despite policy requirements, resulting in the guardian's dissatisfaction.
A resident's medical record lacked documentation of a visitation restriction after a family member threatened harm to staff and residents. The facility did not record the incident or actions taken, such as police contact, in the resident's care plan or medical record, leading to a deficiency.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents. Staff did not perform proper hand hygiene, lacked hair restraints, and failed to label or date food items. The dishwasher was malfunctioning, and staff did not consistently monitor sanitizing solution levels. These deficiencies indicate non-compliance with FDA Food Code and facility policies.
The facility failed to properly label and date medications for four residents, with issues found in two of three medication carts. Medications such as inhalers, eye drops, and nebulizer solutions lacked open or expiration dates and resident names. Additionally, expired Glucerna bottles were found in a medication storage area, which were not removed as required by policy.
The facility failed to follow prescribed dietary requirements and meal plans for several residents, resulting in unmet nutritional needs. Observations revealed that staff did not adhere to menu and meal tickets, leading to residents not receiving appropriate serving sizes or dietary accommodations. Interviews with staff indicated systemic issues such as budget constraints and miscommunication regarding meal preparation.
A resident with a history of falls and moderately impaired cognition experienced multiple unwitnessed falls, and staff failed to complete the required neurological checks according to the facility's policy. The Director of Nursing confirmed the missed checks, highlighting a deficiency in the facility's fall prevention and response procedures.
A resident with moderately impaired cognition and multiple diagnoses, including pleurodynia and PTSD, was placed on 2 liters of oxygen after their oxygen level dropped to 82%. The facility failed to obtain physician orders for continued oxygen use, did not replace oxygen supplies as required, and did not initiate a care plan for oxygen therapy, as confirmed by the ADON.
A facility failed to dispose of a medication properly according to its policy. An RN was observed disposing of a risperidone tablet in a sharps container instead of using the designated chemical compound for drug destruction. The DON confirmed that medications needing to be wasted should be placed in the drug buster. The resident involved had severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia.
A resident prescribed gabapentin for pain was not monitored for potential adverse reactions or side effects, despite having a care plan that should have included such monitoring. Interviews with the ADON and DON confirmed the oversight, acknowledging that staff should have been observing the resident for side effects of the medication.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving two residents, R4 and R5. On November 20, 2024, R5 was observed kicking R4 in the hallway. Despite this incident, the facility did not conduct a comprehensive investigation. The facility's Abuse Prevention Policy requires that any alleged abuse be thoroughly investigated, including interviews with anyone likely to have direct knowledge of the incident. However, the investigation did not include an interview with R5, who, despite severe cognitive impairment, was able to express wants and needs. Additionally, no other staff members besides RN-D were interviewed, and there was no documentation indicating that R5's care plan was revised to include interventions for monitoring behaviors related to resident-to-resident altercations. R4 had severe cognitive impairment with a BIMS score of 3 out of 15 and was discharged to another facility on January 20, 2025. R5, who also had severe cognitive impairment with a BIMS score of 4 out of 15, was discharged home on November 23, 2024. R5's care plan, dated October 30, 2024, noted significant mood distress related to sundowning but did not address resident-to-resident altercations. The Nursing Home Administrator confirmed that R5 was not interviewed and that no other staff interviews were completed to determine if staff had knowledge of R5's aggression. The care plan was not updated after the incident because R5 was scheduled for discharge shortly after the altercation.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents, R3 and R8, as required. R3 was discharged to a community-based residential facility on January 16, 2025, without receiving a written discharge notice, despite being informed of the facility's impending closure a month earlier. Similarly, R8 was transferred to the hospital on January 22, 2025, with a diagnosis of sepsis, but neither R8 nor their legal representative received a written transfer notice. Interviews with the Nursing Home Administrator confirmed that staff did not document the provision of these notices, and the facility did not have a policy related to transfer/discharge notices.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R8 and R10, upon their transfer to a hospital, as required by the facility's policy. R8 was transferred to the hospital on January 22, 2025, with a diagnosis of sepsis, but neither R8 nor R8's legal representative received a bed hold notice. This was confirmed by an interview with R8's guardian, who stated they did not receive the notice when R8 was discharged to the hospital. Similarly, R10 was transferred to the hospital on January 5, 2025, due to critical lab results, but there was no documentation in R10's medical record indicating that a bed hold notice was provided to R10 or their legal representative. A progress note indicated that R10 was discharged from the hospital to another skilled nursing facility on January 10, 2025. The Nursing Home Administrator confirmed that the facility did not have documentation of a bed hold notification being completed and provided to either R8 or R10 and their legal representatives.
Inadequate Infection Control Training and PPE Provision During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, which began on September 14, 2024. Three housekeeping staff members were not provided with appropriate education and personal protective equipment (PPE) prior to and during the outbreak. Specifically, two housekeepers, HK-D and HK-E, were not fit-tested for N95 masks until September 25, 2024, 11 days after the outbreak began. Additionally, HK-E and another housekeeper, HK-C, did not receive education on the facility's COVID-19 procedures until after the outbreak had started. This lack of preparedness had the potential to affect all 45 residents in the facility. The facility's policy required employees to consult with management if they had not been fit-tested for N95 masks before entering the room of a COVID-positive resident. However, HK-D and HK-E worked multiple shifts during the outbreak without fit-tested N95 masks. HK-D worked three shifts and HK-E worked seven shifts in COVID-19 positive areas without the necessary PPE. Interviews with the housekeeping staff and human resources confirmed the absence of documented infection control training for these employees prior to the outbreak. The housekeeping supervisor also confirmed that HK-D and HK-E cleaned COVID-19 positive rooms without the appropriate PPE during the outbreak.
Deficient Catheter Care and Documentation for Two Residents
Penalty
Summary
The facility failed to provide appropriate catheter care and documentation for two residents with indwelling catheters, leading to deficiencies in measuring output and preventing urinary tract infections (UTIs). For one resident, the staff did not hold the catheter tubing at the meatus during catheter care, and the catheter output was not emptied or documented according to the care plan and facility policy. This resident had a history of type 2 diabetes with diabetic chronic kidney disease, retention of urine, obstructive and reflux uropathy, and a UTI. The resident's medical records showed that the catheter bag was not emptied and documented properly on 21 out of 25 days, and there was a previous incident where a large volume of urine was drained in the emergency department, indicating improper catheter maintenance. For the second resident, the staff also failed to empty and document the catheter output per the care plan and facility policy. This resident had diagnoses including neuromuscular dysfunction of the bladder, cystostomy, flaccid neuropathic bladder, type 2 diabetes mellitus, and toxic megacolon. The resident reported that the catheter bag was typically emptied only once a day, usually during the night shift. The documentation confirmed that the catheter output was not properly documented on 15 out of 24 days. Interviews with staff confirmed that catheter bags should be emptied and documented every shift, but this was not consistently done.
Failure to Complete Ordered Video Swallow Study
Penalty
Summary
The facility failed to ensure a resident received a recommended and ordered video swallow study for swallowing difficulties. The resident, who had a history of dysphagia and other medical conditions, was assessed by speech therapy on 6/14/24 and referred for a video swallow study. A physician ordered the study on 7/3/24, but the facility did not complete it. The facility's policy required licensed nurses to confirm and complete physician orders, but this was not adhered to in this case. The resident was admitted for wound care and therapy following a right leg amputation and had severely impaired cognition. Despite the speech therapy evaluation indicating the need for a video swallow study to assess the resident's swallowing safety, the study was not scheduled or completed. The resident was later hospitalized with acute hypoxic respiratory failure, potentially linked to recurrent aspiration pneumonia. Interviews with facility staff, including the Rehab Director and Nursing Home Administrator, confirmed the order was in the resident's medical record, but no explanation was provided for the failure to schedule or complete the study.
Failure to Provide Scheduled Showers and Baths
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for three residents, specifically in relation to scheduled showers or baths. The facility's policy required that showers or bed/sponge baths be offered weekly, with residents having the right to refuse or choose the timing. However, the facility did not adhere to this policy, as evidenced by the experiences of three residents who did not receive regular showers or baths. One resident, who had intact cognition, reported not receiving a shower since before Christmas, despite having skin issues that were potentially exacerbated by lack of hygiene. The resident's medical records showed significant gaps in shower documentation, with only a few showers and bed/sponge baths recorded over several months. Staff interviews revealed that showers were often not completed due to staffing shortages, and there were instances where staff were asked to falsify shower records. Another resident, who had moderate cognitive impairment, also did not receive weekly showers during their stay, with documentation missing for two weeks. A third resident, with intact cognition, reported not receiving weekly showers as scheduled and had to request washcloths and towels to clean themselves. The resident's care plan did not reflect their bathing needs or preferences, nor did it include the facility's practice of pairing staff for care. The Director of Nursing acknowledged the documentation issues and the lack of adherence to the care plan.
Failure to Monitor and Report Skin Injuries
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of skin concerns for a resident, identified as R1, who sustained multiple skin injuries during their stay. R1, who had diagnoses including renal disease, anxiety, and stroke with a traumatic brain injury, was admitted with moderate cognitive impairment. Despite the facility's policy requiring weekly skin assessments and documentation, R1's medical record lacked assessments for the week of admission and discharge, and there were no documented notifications to R1's physician or Power of Attorney for Healthcare (POAHC) regarding the skin injuries. R1 sustained skin tears on three separate occasions, with no documented assessments or notifications to the POAHC or medical doctor. The injuries included a 5 mm x 5 mm skin tear on the right elbow, a 2.5 cm skin tear on the left knee, and two additional tears on the right knee. The facility's Director of Nursing confirmed that weekly skin checks and notifications to the resident's MD and representative were required but not performed. The POAHC expressed concern over the lack of communication and the unknown origins of the injuries.
Failure to Conduct Required Neurological Checks After Resident Falls
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment. The resident experienced three unwitnessed falls during their stay at the facility. Despite the facility's policy requiring neurological assessments after falls, the staff did not complete the required neurochecks for two of the three falls. The resident's medical record indicated falls on three separate occasions, with incomplete neurological assessments documented for the falls on two of those dates. The facility's policy, revised on 9/25/23, mandates specific intervals for neurochecks following a fall, but these were not adhered to in the resident's case. Interviews with the RN and DON confirmed that neurochecks should be completed for unwitnessed falls, yet the documentation was incomplete. The resident's medical history included traumatic subdural hemorrhage, dysphagia, narcolepsy, chronic kidney disease, bipolar disorder, anxiety, and mild cognitive impairment, which necessitated careful monitoring. The failure to conduct thorough neurological assessments as per policy represents a deficiency in the facility's care standards.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident, identified as R1. The deficiency was identified through staff interviews and record reviews, which revealed discrepancies in the administration and documentation of lorazepam, a psychotropic medication prescribed to R1. The facility's policy required medications to be administered according to the prescriber's written orders and documented immediately after administration. However, the records for R1 showed inconsistencies between the Controlled Drug Record/Disposition Form and the Medication Administration Record (MAR). R1 was admitted with multiple diagnoses, including traumatic subdural hemorrhage, dysphagia, narcolepsy, chronic kidney disease, depression, bipolar disorder, anxiety, and mild cognitive impairment. The resident's MARs for July and August 2024 indicated that lorazepam was prescribed with varying administration frequencies, but the documentation did not consistently reflect these orders. For instance, doses were recorded on the MAR without corresponding entries on the Controlled Drug Form, and vice versa. Additionally, some doses were administered at intervals that did not align with the physician's orders. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed the discrepancies. The staff acknowledged that the Controlled Drug Receipt Record/Disposition Form and the MAR should match, and any errors should be reported and addressed. Despite this acknowledgment, the surveyor found missing documentation for several dates, indicating a failure to adhere to the facility's medication administration and documentation policies.
Failure to Notify Guardian of Medication Change
Penalty
Summary
The facility failed to notify a resident's guardian of a significant change in treatment, specifically a reduction in the dosage of clonazepam, an anti-anxiety medication. The Nurse Practitioner (NP) ordered a decrease in the dosage from 1 mg twice daily to 0.5 mg twice daily based on a pharmacy recommendation for a gradual dose reduction. However, the resident's guardian was not informed of this change until over a week later, which led to the guardian noticing increased anxiety in the resident and subsequently requesting the original dosage be reinstated. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for notifying the guardian. The Licensed Practical Nurses (LPNs) involved in processing the order did not ensure the guardian was informed, and there was confusion about who was responsible for this task. The Director of Nursing and the Regional Director acknowledged the guardian's dissatisfaction due to the delay in notification, and the NP confirmed the guardian's upset reaction. The facility's policy required notification of significant treatment changes, which was not adhered to in this instance.
Incomplete Documentation of Visitation Restriction
Penalty
Summary
The facility failed to ensure that a resident's medical record contained complete and accurate information regarding a visitation restriction. The resident, who had intact cognition and was admitted with diagnoses including depression, anxiety, seizure disorder, diabetes, and hypertension, had a baseline care plan that allowed a family member to visit during specified hours. However, a progress note indicated a change in visitation was discussed with the Nursing Home Administrator due to safety concerns, but this change was not documented in the resident's medical record, care plan, or care conference notes. The incident involved a family member who threatened harm to staff and potentially to residents, leading to a suspension of visitation. Despite the severity of the threat, the facility did not document the incident or the actions taken, such as police contact or changes in visitation, in the resident's medical record. The Social Worker confirmed that documentation was not completed following the care conference where the threat was made, and the administration was not alerted immediately. The lack of documentation and timely communication contributed to the deficiency identified by the surveyor.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 53 residents. During an initial tour of the kitchen, it was observed that there was no soap or paper towels available at the handwashing sink, and staff were not performing appropriate hand hygiene. Additionally, staff members were observed handling food without wearing required hair restraints, such as hair nets and beard nets, which are necessary to prevent contamination. The facility also did not properly label or date food items in storage, which is a violation of the 2022 FDA Food Code. During the kitchen tour, multiple undated and unlabeled food items were found in the cooler and dry storage areas, including pitchers of liquids, containers of wafers, sugar, and other food products. The walk-in freezer lacked an internal thermometer, and the Dietary Manager confirmed that all food and beverages should be labeled and dated, and that all coolers and freezers should have thermometers. Furthermore, the facility did not adequately monitor and document dishwasher and surface temperatures. The dishwasher was observed to be malfunctioning, and staff were using a three-compartment sink to wash and sanitize dishes without consistently testing the parts per million (PPM) of the sanitizing solution. The facility's Dish Machine Log-High Temp did not contain internal temperature documentation, and dishwashing temperatures were not recorded for several meals. The lack of proper monitoring and documentation of sanitizing procedures indicates a failure to adhere to the facility's policies and guidelines.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications for four residents were properly labeled and dated, as observed in two of the three medication carts. Specifically, medications such as inhalers, eye drops, and nebulizer solutions lacked open or expiration dates and resident names. This included a Fluticasone prop nasal spray and a Combivent inhaler for one resident, an Albuterol nebulizer solution package and a Ventolin inhaler for another, an Anoro Ellipta inhaler for a third resident, and an Ipratropium/Albuterol inhaler and a bottle of Artificial Tears for a fourth resident. The Director of Nursing confirmed that these medications should have been labeled with the resident's name and open or expiration dates according to the facility's policy. Additionally, the facility did not remove expired supplements from one of the two medication storage areas. During an observation, three bottles of Glucerna with expired dates were found stored on a shelf. A Registered Nurse confirmed the Glucerna was outdated and should have been removed, and subsequently contacted the Assistant Director of Nursing to address the issue. These findings indicate a failure to adhere to the facility's policies regarding medication labeling and storage, as well as the removal of expired products.
Failure to Follow Prescribed Diets and Meal Plans
Penalty
Summary
The facility failed to adhere to prescribed dietary requirements and meal plans for six residents, leading to unmet nutritional needs. During multiple meal observations, staff did not follow the menu and meal tickets, resulting in residents not receiving the appropriate serving sizes or dietary accommodations. For instance, residents were not offered cereal as per the menu, and those requiring double portions or specific dietary restrictions did not receive them. This was evident during breakfast and lunch meals over several days, where residents expressed dissatisfaction with the quantity and type of food served. The report highlights specific cases where residents with medical conditions such as severe protein calorie malnutrition, chronic kidney disease, and end-stage renal disease did not receive meals according to their dietary needs. One resident, who required a low concentrated sweet and no added salt diet, received inappropriate food items like wheat bread and canned fruit, contrary to their dietary restrictions. Another resident, who had a grievance resolved to receive double portions, did not receive the agreed-upon meal adjustments. Interviews with staff, including the Food Service Director and kitchen staff, revealed systemic issues such as budget constraints and miscommunication regarding meal preparation and serving. The Food Service Director acknowledged the problem of insufficient portions and the failure to follow meal tickets, attributing it to budget limitations and errors in meal ticket production. Staff also reported that residents frequently complained about inadequate food portions, and some staff attempted to compensate by combining extra trays when available.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed according to policy for a resident who experienced multiple falls. The resident, who had a history of falls and moderately impaired cognition, was admitted with diagnoses including palliative care and anxiety. The facility's policy required neurological assessments after head injuries or changes in condition, with a specific schedule for neurochecks. However, staff did not consistently complete these checks following the resident's unwitnessed falls on several occasions. The resident's medical record indicated unwitnessed falls on four separate dates, with staff missing a total of 16 neurochecks across these incidents. The Director of Nursing confirmed the missed neurochecks and stated that nurses were expected to complete them as per the facility's neurological flow sheet. This failure to adhere to the established protocol for neurological assessments after falls represents a deficiency in the facility's fall prevention and response procedures.
Failure to Ensure Proper Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide necessary respiratory care and treatment for a resident, identified as R32, who was placed on 2 liters of oxygen. The deficiency was identified through observation, staff interviews, and record reviews. The facility's Oxygen Administration policy requires obtaining a physician order if oxygen is continued beyond 24 hours, replacing oxygen tubing weekly, and observing skin integrity behind the ears daily. However, the staff did not obtain physician orders for the use of oxygen or the cleaning and replacement of supplies, nor did they initiate a care plan when R32 was placed on oxygen. R32, who was admitted to the facility with a history of tobacco use and diagnoses including pleurodynia, diabetes, hyperlipidemia, anxiety, and PTSD, had a BIMS score indicating moderately impaired cognition. On a specific date, R32's oxygen level dropped to 82%, prompting staff to administer oxygen. Despite this, R32's medical record lacked a care plan for oxygen use and did not specify when the oxygen equipment should be cleaned or replaced. The Medication Administration Record and Treatment Administration Record also did not contain orders for oxygen, which was confirmed by the Assistant Director of Nursing.
Improper Medication Disposal
Penalty
Summary
The facility failed to properly dispose of a medication in accordance with its Medication Destruction policy. During an observation, a Registered Nurse (RN) was seen disposing of a risperidone tablet in a sharps container after it fell on top of the medication cart. This action was not in line with the facility's policy, which requires non-controlled, non-hazardous medications to be destroyed using a chemical compound for drug destruction. The Director of Nursing confirmed that medications needing to be wasted should be placed in the drug buster, not a sharps container. The resident involved, identified as R27, was admitted to the facility with diagnoses including Alzheimer's disease, dementia, anxiety, and depression. The Minimum Data Set (MDS) assessment indicated that the resident was severely cognitively impaired and rarely understood. This incident highlights a deviation from the facility's established procedures for medication disposal.
Failure to Monitor Adverse Reactions to Gabapentin
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for potential adverse reactions to gabapentin, an anticonvulsant medication. The resident, who was admitted with diagnoses including anxiety, depression, borderline personality disorder, bipolar disorder, and type 2 diabetes mellitus with diabetic neuropathy, had a BIMS score indicating intact cognition. Despite having an order for gabapentin to be administered twice daily, the resident's care plan lacked interventions for monitoring adverse reactions or side effects such as drowsiness, dizziness, blurred vision, and other symptoms associated with gabapentin. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that staff did not monitor the resident for side effects of gabapentin. The Assistant Director of Nursing acknowledged that the resident was prescribed gabapentin for pain and that staff should have been monitoring for side effects. The Director of Nursing also verified the lack of monitoring and indicated that staff should have been observing the resident for adverse reactions to the medication.
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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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