Chi Franciscan Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in South Milwaukee, Wisconsin.
- Location
- 3601 S Chicago Ave, South Milwaukee, Wisconsin 53172
- CMS Provider Number
- 525526
- Inspections on file
- 40
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Chi Franciscan Villa during CMS and state inspections, most recent first.
A resident with multiple comorbidities, comatose status, and total dependence for mobility developed a facility-acquired stage 3 buttock pressure injury and an unstageable DTI on the ankle despite documented risk and care plan interventions such as an air mattress, q2h repositioning, and bilateral heel boots. Surveyors observed on multiple occasions that the resident was lying on her back without pressure-relieving boots and with feet not properly offloaded, sometimes resting directly on the mattress or laterally on a flattened pillow. The facility lacked a detailed pressure injury policy, did not document a root cause for the stage 3 injury, and did not update the care plan to address the development of the new pressure injury.
Two residents did not receive adequate supervision and safety measures to prevent accidents. One resident with severe cognitive impairment, wandering behavior, and a documented fall risk had a care-planned low bed intervention that was not in place; the bed was found at waist height after the resident was discovered walking in the hall with facial bleeding, and documentation indicated the resident likely raised the bed using the remote. The facility’s investigation did not explain the lack of supervision or why the low-bed intervention was not in place despite documented restlessness and wandering. Another resident with a trach, chronic respiratory failure, dysphagia, and functional quadriplegia had speech therapy and care plan orders for a mechanical soft diet, supervision with meals, and use of a Passy Muir speaking valve during all PO intake, yet was observed eating independently without supervision and later with a meal tray present, no PMSV in place, and no staff supervision for an extended period, contrary to the facility’s own meal supervision policy.
The facility failed to provide sufficient nursing staff to meet residents’ needs, as shown by PBJ data and schedules indicating frequent understaffing of CNAs, nurses, and CMAs, especially on weekends. Staff interviews revealed that frequent call-ins led to short staffing, requiring nurses to assist with CNA tasks and causing staff to fall behind, with acknowledgment that residents were affected. Surveyors observed delayed responses to call lights, including one resident whose call light remained on for 16 minutes while staff walked by, and another resident who requested bathroom assistance, had the call light turned off and was told to wait, then had to reactivate the call light and wait several more minutes before help arrived. The NHA acknowledged past staffing challenges but provided no further explanation for the low staffing or delayed call light responses.
A resident with CHF, lymphedema, morbid obesity, PVD, and a history of falls, who was cognitively intact and required assistance with bathing, transfers, and dressing, was observed being wheeled in a shower chair down facility hallways by a CNA while wearing a hospital gown that left the resident’s hip and side of the buttocks exposed. This transport route passed the main entrance and multiple hallways, contrary to the facility’s dignity policy requiring protection of bodily privacy during personal care. The resident later stated dissatisfaction with being exposed and indicated not knowing the skin was uncovered.
A resident with complex medical conditions, including anoxic brain damage, respiratory failure with hypoxia, trach and G-tube status, morbid obesity, CHF, and a comatose BIMS score, was the subject of a family grievance alleging inadequate turning and repositioning, feces on sheets, infrequent checks, and possible trach infection. The grievance form showed that the SW and DON met with the guardian and marked the concern as resolved, but there was no documented investigation, findings, confirmation status, or corrective actions as required by the facility’s grievance policy. The current DON could not locate any additional follow-up documentation, and the resident’s guardian reported that the same care concerns continued and that no changes were made after the grievance was filed.
A resident with Alzheimer’s disease, delirium, and CKD stage 3B, who was documented as rarely/never understood and exhibiting behavioral symptoms, had a missing wedding ring reported by the spouse to facility staff, who completed a grievance form and confirmed the ring was not among the resident’s belongings. The spouse subsequently reported the missing white gold diamond wedding ring to local police after being told by the Admissions Director that the ring was not at the facility. Despite the facility’s abuse policy identifying missing property as a possible indicator of abuse, the NHA did not treat the incident as misappropriation, stating the spouse indicated it was misplaced, and the allegation was not reported to the State Survey Agency within the required timeframe, resulting in a delayed report of suspected misappropriation.
A resident with chronic respiratory failure, an indwelling trach, chronic encephalopathy with delirium, and multiple comorbidities repeatedly pulled out her trach tube, an event documented at least 28 times and leading to numerous 911 calls and ER transfers when reinsertion was unsuccessful. Although the care plan addressed general trach care and anti-anxiety medication use, it did not include specific, person-centered interventions for the resident’s ongoing behavior of removing the trach. The DON acknowledged the behavior occurred daily and cited increased Ativan use, proximity of the resident’s room to the nurses’ station, and a believed but undocumented psych consult request, yet the surveyor found no evidence of additional interventions or a comprehensive behavior-focused care plan, and trach care and treatment were not included in the Facility Assessment.
A resident with multiple medical conditions and intact cognition, who required supervision and assistance for bathing and dressing per the care plan, did not receive the ordered twice-weekly showers on numerous scheduled dates over several months. The resident reported not getting daily showers and could not recall the last one, and was observed wearing food-stained clothing. Facility policy required support for ADLs, including hygiene, and the DON stated CNAs must complete shower sheets and document refusals, but no shower documentation could be produced for the missed dates.
A resident with Alzheimer’s disease, delirium, and CKD stage 3B was receiving warfarin and clopidogrel without a baseline care plan for anticoagulant/antiplatelet monitoring. The resident got out of bed, pulled out an indwelling Foley catheter, left the room, and fell, after which an RN documented abrasions, penile bleeding from traumatic catheter dislodgement, and reinsertion of the catheter with initial blood clots. Over the following hours, staff documented ongoing hematuria, dried blood around the genital area, and a Foley that appeared partially dislodged, and the unit manager later stated the resident was being monitored on a 24-hour board, but no supporting documentation of monitoring or serial assessments was produced. Surveyors found limited documentation of assessment and monitoring of the resident’s hematuria and condition during the several hours between the fall/catheter trauma and the resident’s eventual transfer to the hospital for hematuria.
A resident's legal representative was not granted access to medical records after submitting a written request, even after being named Power of Attorney for Health Care. The facility did not act on the request following the change in the resident's decision-making status, resulting in the records not being released.
Two residents experienced deficiencies in accident prevention and fall risk management. One resident fell from bed and sustained a femur fracture when a CNA failed to follow proper turning protocols during care. Another resident, at risk for falls, did not have required reminder signage or trip hazards removed from their room, and their fall risk assessment was not accurately completed, leading to a fall during an attempted self-transfer.
A resident with significant medical conditions developed a new unstageable pressure ulcer on the left posterior ankle, which was not present on prior assessments. The facility did not notify the resident's representative of this new injury, as required by policy, and documentation confirming such notification was absent. The DON confirmed the omission after reviewing the records.
A resident with complex medical needs, including a tracheostomy and persistent vegetative state, had multiple instances of missing documentation in the electronic medical record for essential care tasks such as suctioning assessments, trach site cleansing, and inner cannula changes. Nursing staff and the DON confirmed that these omissions in the Treatment Administration Record indicated the required care may not have been performed as ordered.
A resident with a tracheostomy and complex medical history received care during which the RT failed to disinfect the table before placing supplies, contaminated sterile gloves by touching them with dirty gloves, and did not perform required hand hygiene or glove changes between steps. These actions did not follow the facility's infection control policy for tracheostomy care.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were insufficient to minimize accident risks.
The facility did not fully investigate an allegation of narcotic medication misappropriation after controlled medication discrepancies were found involving a nurse. Although several residents were affected, not all had documented pain evaluations or interviews to assess outcomes, and the investigation lacked complete documentation for all potentially impacted individuals.
The facility did not report a suspected diversion of narcotic medications to the State Survey Agency within the required timeframe after discovering multiple controlled medication discrepancies involving an RN. The incident was reported late due to internal investigation and corporate direction.
The facility failed to ensure that a DT received required supervision from an RD in the assessment and ongoing nutritional care of two residents, including those with pressure ulcers, diabetes, recent stroke, and significant weight loss. The DT completed nutritional assessments and progress notes without RD review or consultation, and the RD was unaware of high-risk cases and did not routinely review or sign off on assessments.
Staff did not follow enhanced barrier precautions during wound care for a resident with venous stasis ulcers. Despite clear facility policy and signage requiring the use of gowns and gloves for chronic wound care, staff only wore gloves and omitted gowns. The nurse involved believed gowns were only necessary for draining wounds, contrary to the facility's policy, which was confirmed by the unit manager.
A resident's MDS assessments were inaccurately coded, with the quarterly assessment reflecting an incorrect weight and the discharge return anticipated assessment documenting an incorrect number of unstageable wounds. The errors were confirmed by the MDS Coordinator, despite facility policy and RAI manual requirements for accuracy.
Two residents dependent on staff for bathing did not consistently receive scheduled showers, and staff failed to properly document refusals or interventions as required by facility policy. Incomplete records and lack of nurse sign-off were found, despite care plans and orders specifying the need for substantial or total assistance and thorough documentation.
A resident with severe cognitive impairment, stroke, and swallowing difficulties experienced significant weight loss after admission due to inadequate oversight by the RD over the DT. The DT completed the nutritional assessment and made care plan changes without the RD's knowledge, and the resident was frequently left without proper feeding assistance, resulting in poor meal intake and further weight loss.
A resident with quadriplegia was subjected to verbal and mental abuse by a CNA who removed the resident's call light and closed the door, leaving them unable to summon help. The incident was not reported to the NHA immediately, allowing the CNA to continue working for additional shifts. This failure to protect the resident and report the abuse promptly resulted in a finding of immediate jeopardy.
A facility failed to report an allegation of abuse immediately, allowing a CNA accused of misconduct to continue working for three additional shifts. The incident involved a resident with quadriplegia, whose call light was removed by the CNA. The RN who was informed of the incident did not report it to the administration, delaying the investigation and reporting to the State Survey Agency.
The facility allowed CNAs to administer medications on the Heritage unit during a nurse shortage, contrary to policy and state regulations. The DON instructed CNAs to deliver medications under RN supervision, a practice not permitted without specific training. The NHA was aware but deferred to the DON's decision.
Three residents experienced verbal abuse from two staff members, with one CNA threatening and ridiculing residents during mealtime, and another CNA making racially insensitive remarks during ostomy care. The incidents were reported by witnesses, leading to administrative actions against the involved staff.
Failure to Implement Pressure Injury Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with professional standards of practice for a resident who was at high risk for skin breakdown. The resident was admitted with multiple serious medical conditions, including anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder, and anxiety. The resident’s MDS documented that she was comatose, had impaired upper and lower extremities bilaterally, was dependent on staff for rolling and mobility in bed, and was at risk for development of pressure injuries. The Care Area Assessment noted she was at risk for skin impairment and that preventive measures such as a pressure-reducing mattress, wheelchair cushion, and weekly skin checks were in place. Her CNA Kardex and care plan documented that she required two staff for repositioning every two hours and bilateral heel boots to offload pressure to her heels, and that she had an air mattress set to her weight for wound prevention and healing. Despite these identified risks and documented interventions, the resident developed a facility-acquired stage 3 pressure injury on the left buttock and an unstageable deep tissue injury (DTI) on the right lateral ankle. Wound physician notes described an unstageable DTI of the right lateral ankle with intact skin and purple/maroon discoloration and a stage 3 pressure wound of the left buttock with full-thickness tissue loss and granulation tissue. Subsequent wound notes continued to document the unstageable DTI on the right lateral ankle and the stage 3 pressure injury on the left buttock. The facility did not provide a pressure injury policy and procedure to surveyors, only a general “Pressure Injuries Overview” form that contained definitions and staging information but no procedural guidance. Surveyors observed multiple instances where the resident’s care plan interventions for pressure relief were not implemented. On several observations over multiple days, the resident was seen lying on her back in bed without pressure-relieving boots, with her feet either resting laterally on a pillow or directly on the mattress, and not properly offloaded. Only one observation noted a pillow under her legs to float her heels, but the pillow was flattened and both feet were still resting laterally on the pillow. The facility did not document a root cause for the development of the stage 3 left buttock pressure injury, and the resident’s care plan was not updated to include interventions addressing the potential root cause of that pressure injury. When questioned, the DON stated the facility believed the root cause was related to the incontinence product edge lying over the wound, but no additional information was provided explaining why the DTI and stage 3 pressure injury developed or why the ordered preventive interventions were not in place as observed by surveyors.
Failure to Provide Adequate Supervision and Safety Measures to Prevent Falls and Choking
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident with Alzheimer’s disease, severe cognitive impairment (BIMS score of 5), wandering behavior, and a documented fall risk score of 10 had a care plan intervention for the bed to be in the lowest position. Despite this, on the day of the incident, the resident’s bed was found at about waist height after the resident had been seen resting in bed in the lowest position 20–30 minutes earlier. The resident was later found walking in the hallway with a walker, bleeding from the head, face, nose, and mouth, and staff documentation and the fall protocol checklist indicated that the bed was high and that the resident likely raised the bed using the remote, which was found next to the side rail. The same resident had prior documentation of restlessness, combative behaviors, and wandering into other residents’ rooms on the day of the fall. Nursing notes indicated the resident was being monitored for these behaviors and that she was easily redirected and cooperative, but the facility’s fall investigation and self-report did not address why adequate supervision was not provided at the time of the fall, despite these behaviors. The surveyor noted that the fall intervention of a low bed was not in place at the time of the fall and that no additional information was provided by facility leadership explaining the lack of supervision and the absence of the low-bed intervention when the fall occurred. A second deficiency involved another resident with chronic respiratory failure, tracheostomy status, laryngeal hypoplasia, epilepsy, obesity, functional quadriplegia, type 2 diabetes, and dysphagia, who had speech therapy recommendations and a care plan requiring a mechanical soft diet, supervision during meals, and use of a Passy Muir speaking valve (PMSV) during all PO intake. The facility’s own Meal Supervision and Assistance policy required adequate supervision during meals based on assessed needs and identified risks. During one observation, the resident was found in bed with a lunch plate on the lap, eating independently and having consumed at least half of the meal before a unit manager entered, placed a cap on the trach, and stated she would stay because the resident needed supervision when eating. On another observation, the resident was lying in bed with the head of bed elevated, the lunch tray in front, the PMSV not in place, and no staff entering the room to supervise for 27 minutes, despite the documented need for supervision with meals and PMSV use during all PO intake.
Insufficient Nursing Staff and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly during October, as evidenced by staffing records, staff interviews, and call light response observations. Review of PBJ (Payroll Based Journal) data from July through December showed the facility triggered for one-star staffing and excessively low weekend staffing, with October schedules and daily staffing postings revealing that on 21 of 31 days, CNA staffing did not meet the facility’s own deemed appropriate numbers, and all four weekends were understaffed. Nurse and Certified Medication Assistant staffing was also below the facility’s targets on six days, four of which were weekends when CNA staffing was also short. Staff interviews, including CNAs, an LPN, a CMA, and the scheduler, consistently cited frequent call-ins as a cause of short staffing and acknowledged that nurses had to assist with CNA duties, that staff got behind, and that residents were affected when shifts were short. Surveyors directly observed delayed responses to resident call lights, further demonstrating the impact of insufficient staffing on resident care. One resident’s call light remained activated for 16 minutes while multiple staff members walked past the room before anyone entered. In another instance, a CNA entered a resident’s room after a call light was activated, was told the resident needed to use the bathroom, turned off the call light, instructed the resident to wait, and left; the resident reactivated the call light 10 minutes later, and it was approximately five minutes more before another staff member entered the room. The Nursing Home Administrator acknowledged staffing challenges in October and November and stated that nurse managers were present on weekends providing care, but the facility did not provide additional information to address the surveyor’s concerns about low staffing or the delays in answering call lights.
Resident Exposed During Transport to Shower, Violating Dignity and Privacy
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and bodily privacy during transport to the shower. A surveyor observed a certified nursing assistant (CNA-C) wheeling Resident 7 down the South hallway, past the main entrance, and halfway down the North hallway to the shower room while the resident was seated in a shower chair wearing a hospital gown with the left hip and side of the buttocks exposed. The facility’s undated “Dignity” policy states that each resident shall be cared for in a manner that promotes well-being, self-worth, and self-esteem, and that staff must promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures. Resident 7 had been admitted with diagnoses including congestive heart failure, lymphedema, morbid obesity, peripheral vascular disease, and a history of falls, and had a BIMS score of 14 indicating intact cognition. The resident’s care plan documented needs for partial to moderate assistance with bathing and showering, and supervision or assistance with ambulation, transfers, and dressing. After the observed incident, the resident reported being unhappy that her skin was exposed while being wheeled through the hallways to the shower and stated she did not know her skin was exposed and that she was not an exhibitionist. The nursing home administrator and DON were notified of these dignity concerns and acknowledged them.
Failure to Follow Grievance Policy and Document Resolution of Care Concerns
Penalty
Summary
The facility failed to follow its grievance policy and ensure prompt resolution and proper documentation of a grievance related to a resident’s care. A resident with anoxic brain damage, acute respiratory failure with hypoxia, tracheostomy and gastrostomy status, morbid obesity, congestive heart failure, major depressive disorder, anxiety, and a BIMS score indicating coma was the subject of a grievance filed by the resident’s family/guardian. The written grievance documented concerns that the resident was not being turned as frequently as needed, had feces on the sheets, was not being checked on as often as the family desired, and that the tracheostomy might be infected. The grievance form noted that the SW and DON met with the guardian, that the family wanted the resident checked at a hospital for possible trach infection, and that the concern was marked as resolved with the family reportedly satisfied with the plan. Despite the facility’s written policy requiring the Grievance Official to oversee the process, investigate, and issue a written decision including the steps taken, findings, confirmation status, and corrective actions, there was no evidence of follow-up or resolution beyond the initial notation on the grievance form. The current DON reported she had no additional information and could not locate any further documentation related to the grievance. The resident’s guardian later stated that the same concerns about turning, repositioning, checking on the resident, use of boots, and development of bed sores persisted and that no one addressed or changed anything after the grievance was filed. Surveyors found no additional information when the NHA and DON were notified of concerns regarding grievances.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to timely report a reasonable suspicion of a crime, specifically an allegation of misappropriation of a resident’s property, to the State Survey Agency as required by Section 1150B of the Act and the facility’s own Abuse, Neglect, and Exploitation policy. The policy, effective 5/22/25, identifies resident reports of theft or missing property as possible indicators of abuse that require action. The resident involved had Alzheimer’s disease, delirium, and stage 3B chronic kidney disease, and was documented on the Admission/Medicare 5-day MDS as rarely/never understood and rarely/never understanding others, with behavioral symptoms occurring 1–3 days in the look-back period. On 12/2/25, the resident’s wife called the facility and reported that the resident’s wedding ring was missing; staff documented this on a Resident/Family Concern/Grievance Report form, and the ring was not found among the resident’s belongings. On 12/3/25, the resident’s wife went to the South Milwaukee Police Department and reported that she had contacted the facility and spoken with the Admissions Director, who confirmed they did not have the ring. She stated she last saw the ring on the resident’s finger on November 30 and described it as a white gold men’s wedding ring with diamonds. Despite this report to the facility and the subsequent police report, the allegation of misappropriation was not reported to the State Survey Agency until 12/9/25, outside the required timeframe. During an interview on 2/17/26, the Nursing Home Administrator stated that the wife never indicated the ring was stolen, only misplaced, and therefore the incident was not reported as misappropriation. The surveyor informed the administrator that the missing wedding ring constituted an allegation of misappropriation that should have been reported on 12/2/25, and later informed the DON of the concern regarding the delayed reporting. No additional information was provided regarding the delay in reporting the allegation to the State Survey Agency.
Failure to Develop Comprehensive Care Plan for Resident Repeatedly Removing Tracheostomy Tube
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s repeated behavior of pulling out her tracheostomy tube. The resident was admitted with multiple complex diagnoses, including chronic respiratory failure with an indwelling tracheostomy, chronic encephalopathy with delirium, laryngeal hypoplasia, epilepsy, anxiety disorder, obesity, functional quadriplegia, dysphagia, and type 2 diabetes mellitus. Her History and Physical documented that she remains in a chronic encephalopathic state with delirium and repeatedly pulls out tubes and her tracheostomy at the nursing home. The existing care plan noted that she has a tracheostomy and is at risk for shortness of breath, with approaches such as ensuring trach ties are secured and outlining tube-out procedures, and it also documented that she uses anti-anxiety medications and that she pulls out her trach often, with approaches limited to administering anti-anxiety medications and monitoring for side effects and effectiveness. Despite documentation in the H&P and progress notes that the resident has pulled out her trach tube at least 28 times since admission, resulting in at least 18 calls to 911 and transfers to the ER when staff could not reinsert the tube, the facility did not create or implement a specific care plan with targeted interventions for this behavior. The DON reported that the resident pulls out her trach daily, sometimes multiple times a day, and stated that Ativan had been increased and that the hospital uses wrist restraints, which the facility does not use. The DON also stated she thought the facility had requested a psychiatric consultation that was refused by the resident’s son, but she was unable to provide evidence that such a consult was ordered or refused. The DON further reported that the resident’s room placement near the nurses’ station allowed for more frequent checks, but the surveyor found no evidence of implemented interventions beyond increasing Ativan, and noted that tracheostomy care and treatment were not included in the Facility Assessment.
Failure to Provide Scheduled Showers and Maintain Resident Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically bathing and hygiene, to maintain a resident’s grooming and personal hygiene as required by facility policy and the resident’s care plan. The facility’s ADL policy states that residents who cannot independently perform ADLs will receive services to maintain good grooming and personal hygiene, including assistance with bathing, dressing, and grooming in accordance with the plan of care. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including dysphagia, cerebral infarction, COPD, CHF, and muscle weakness, required supervision or touching assistance for showering, bathing, dressing, transfers, and walking with a walker, and was care planned to receive supervision or touching assistance by one staff for bathing and moderate assistance for lower body dressing. Despite the care plan and an EMR order for twice-weekly showers, the resident did not receive documented showers on multiple scheduled dates over several months, including numerous missed showers in July, August, September, and October. During an interview, the resident reported not receiving a daily shower and was unable to recall the last shower. On observation, the resident was seen sitting in a recliner wearing personal clothes that were soiled with food stains on the shirt and pants. The DON stated that CNAs are required to complete shower sheets and document refusals, and that these sheets are kept for about one month, but the facility was unable to produce any shower sheets for the resident and acknowledged concerns about the lack of documented showers on the identified dates.
Failure to Monitor Anticoagulated Resident After Traumatic Foley Catheter Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a newly admitted resident who was on both an anticoagulant (warfarin) and an antiplatelet (clopidogrel). The resident had diagnoses including Alzheimer’s disease, delirium, and stage 3B chronic kidney disease, and the MDS documented severe communication impairment and behavioral symptoms. Despite physician orders for warfarin and clopidogrel, there was no baseline care plan created for monitoring the resident’s use of these blood-thinning medications, and the DON later acknowledged there would be an expectation for monitoring for bleeding and bruising and PT/INR labs for warfarin. On the night in question, the resident got out of bed, pulled out the indwelling Foley catheter, left the room, and fell outside the room door. A Fall Protocol Checklist recorded the fall time as 23:30, while an RN progress note documented the event at 00:30, creating a discrepancy in the recorded time of the fall. The RN note described the resident as aggressive toward staff, with abrasions to the left forearm and left lower back, and bleeding from the penis likely due to traumatic catheter dislodgement. The RN reinserted the catheter, noting initial drainage of blood clots that then thinned out, and documented the resident’s complaint of bladder pain. Following this event, the resident continued to have hematuria. A medication administration note the next morning documented that the resident was in pain from the dislodged Foley, had hematuria in the Foley line and bag, that the Foley appeared partially out, and that there was dried blood around the penis. A subsequent progress note documented dried blood around the penis, groin, and right leg, blood throughout the Foley tubing and into the bag, and that the Foley securement device suggested the catheter had been pulled and dislodged. The unit manager reported that hematuria had been noted the previous day and that the resident was being monitored on a 24-hour board, but no documentation of such monitoring or ongoing assessments was provided. Surveyors identified a lack of documented assessments and monitoring of the resident’s hematuria and condition during approximately eight hours between the catheter trauma and the resident’s transfer to the hospital for hematuria.
Failure to Provide Medical Records to Legal Representative After POA Activation
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's medical records to the resident's legal representative after a written request was made. Initially, the resident was responsible for their own decisions, and the family member's request for records was denied because the Power of Attorney for Health Care (POAHC) had not yet been activated. The facility's policy required a properly executed authorization from the resident or their legal representative for release of records. The family member signed an authorization form, but it was not valid since the resident had not authorized it and was in the hospital at the time. Subsequently, the resident's POAHC was activated, naming the same family member as the legal representative. Despite this change in status, the facility did not revisit or act upon the original request for medical records. Interviews with the POAHC agent and the Nursing Home Administrator confirmed that the request remained unaddressed after the POAHC was activated, and no records were provided to the legal representative. The resident had diagnoses including End Stage Renal Disease, altered mental status, and a stage 4 sacral pressure ulcer at the time of the incident.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for two of three residents reviewed. One resident, with diagnoses including cerebral palsy, hemiplegia, and mild cognitive impairment, required total assistance for incontinence care and personal hygiene. During daily ADL care, a CNA attempted to turn the resident away from themselves to perform incontinence care, resulting in the resident rolling out of bed and sustaining a displaced intertrochanteric fracture of the right femur. Staff interviews revealed that facility training instructs staff to roll residents toward themselves or to seek assistance if a resident must be turned away, but this protocol was not followed in this instance. Another resident, with a history of epilepsy, breast cancer, and chronic pain syndrome, was identified as being at risk for falls and required supervision for bed mobility and transfers. The resident's care plan included interventions such as placing reminder signs in the room and removing trip hazards, but these interventions were not implemented. The resident experienced a fall while attempting to self-transfer from a wheelchair to a commode. During the survey, a folded-up sheet was observed on the floor in the resident's room, which staff acknowledged as a trip hazard, but it had not been addressed or documented in the care plan. Additionally, the required reminder signage was not present in the room. The facility's fall risk evaluation for the second resident was not completed accurately, as the assessment failed to account for the number of high-risk medications the resident was taking, which would have resulted in a higher fall risk score. Staff interviews confirmed that the fall risk evaluation was not properly completed, and there was a lack of clarity among staff regarding the process for addressing resident requests that may pose safety risks. These deficiencies demonstrate a failure to implement and monitor individualized interventions and assessments as outlined in the facility's own policies.
Failure to Notify Representative of New Pressure Ulcer
Penalty
Summary
The facility failed to notify a resident's representative of a newly developed pressure ulcer. Record review showed that the resident, who was in a persistent vegetative state with diagnoses including acute respiratory failure, anoxic brain damage, and congestive heart failure, was readmitted to the facility. Initial skin checks and hospital discharge documents did not indicate a wound on the resident's left posterior ankle. However, a wound care provider later documented an unstageable, full-thickness pressure ulcer with necrosis on the left posterior ankle, noting it as present on admission per staff. Despite this new finding, there was no documentation in the nursing progress notes that the resident's representative was notified of the pressure injury. The Director of Nursing confirmed that the representative should have been notified when the wound was identified by the wound care provider. The facility's policy requires notification of the resident, physician, and family or legal representative when significant changes, such as the development of a pressure injury, occur. Interviews with staff and review of records confirmed the lack of required notification.
Incomplete Medical Record Documentation for Resident with Tracheostomy
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with significant medical needs, including acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure. The resident was documented as being in a persistent vegetative state with a tracheostomy. Review of the electronic medical record revealed missing documentation in the Treatment Administration Record (TAR) for several critical care tasks, including assessment for suctioning every two hours and as needed, cleansing of the tracheostomy site every shift, and changing or cleaning the inner cannula every 12 hours. Specific dates and times were identified where the required documentation was absent, as evidenced by empty boxes with no nurse initials. Interviews with a registered nurse and the Director of Nursing confirmed the missing documentation on the TARs for the months reviewed. Both staff members acknowledged that the absence of documentation meant the tasks may not have been completed as ordered, as the process requires nurses to sign off on each task as it is performed. The deficiency was limited to the lack of documentation for the required treatments and care tasks for the resident during the specified period.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified during tracheostomy care for a resident with a history of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure, who was in a persistent vegetative state and had a tracheostomy. During observation, the Respiratory Therapist (RT) failed to disinfect the table before placing tracheostomy supplies on it and opened a sterile suction tray while wearing gloves that had already been used. The RT then contaminated the sterile gloves by touching them with the dirty gloves and proceeded to suction the resident. After suctioning, the RT did not remove the inner pair of gloves or sanitize hands before donning a new pair of clean gloves, and continued to handle sterile supplies and perform care without proper hand hygiene or glove changes as required by facility policy. Interviews with the RT and the Director of Nursing confirmed that the RT did not follow infection control protocols, including failing to disinfect surfaces, contaminating sterile gloves, and not performing hand hygiene between glove changes. Review of the facility's tracheostomy care policy indicated that gloves should be changed and hands sanitized at specific steps, which was not followed during the observed care. These actions and inactions led to a failure to adhere to infection prevention and control guidelines during tracheostomy care for the resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Thoroughly Investigate Narcotic Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of narcotic medication misappropriation after multiple controlled medication discrepancies were identified involving a registered nurse. The facility's own documentation showed that controlled medications were signed out in the control log but not documented in the Medication Administration Record (MAR) for 17 residents. Despite this, only a portion of the affected residents were assessed for pain outcomes, and there was a lack of documented follow-up pain evaluations for 9 out of 14 residents listed in the facility's self-reported incident. Interviews with facility leadership revealed that the investigation into the medication discrepancies was incomplete, as not all affected residents were interviewed or had their pain outcomes evaluated and documented. The Director of Nursing stated that both verbal and written pain evaluations were conducted, but not all were documented. No evidence was provided to show that all residents potentially impacted by the medication discrepancies were properly assessed, resulting in an incomplete investigation of the alleged violation.
Delayed Reporting of Suspected Medication Diversion
Penalty
Summary
The facility failed to submit a Facility Reported Incident regarding a possible diversion of narcotic medications to the State Survey Agency within the required timeframe. On 05/30/2025, the facility became aware of multiple controlled medication errors and identified a registered nurse as responsible for the discrepancies. Despite this, the incident was not reported to the State Survey Agency until 06/02/2025. During an interview, the Nursing Home Administrator stated that corporate advised against immediate reporting while the facility continued its internal investigation to determine if misappropriation had occurred, resulting in a delayed report beyond the mandated period.
Lack of Registered Dietician Oversight in Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the Dietary Technician (DT) received appropriate oversight and supervision from the Registered Dietician (RD) in the assessment and ongoing nutritional care of two residents. According to the 2024 Scope and Standards of Practice for Nutrition and Dietetics Technician, Registered, NDTRs must work under the clinical supervision of an RDN when engaged in direct patient nutrition activities, and the RDN is responsible for completing nutritional assessments and supervising technical staff. However, documentation for both residents showed that the DT completed nutritional assessments and progress notes without evidence of RD review or consultation, even in high-risk cases. One resident was admitted with multiple pressure ulcers and diabetes, and experienced significant weight loss over a 90-day period. The DT documented all aspects of the nutritional assessment and progress notes, including diet orders, weight trends, and interventions, but there was no indication that the RD had reviewed or participated in these assessments. The DT also signed progress notes as the dietician, and during interviews, described managing the resident’s nutritional care independently, including offering supplements and adjusting menus based on preferences and intake, without documented RD involvement. Another resident was admitted after a recent stroke with difficulty swallowing and experienced a notable weight loss within one week of admission. The DT again completed the nutritional assessment and implemented interventions such as fortified foods and weekly weights, but there was no documentation of RD oversight or consultation. Interviews with the RD revealed that she relied on the DT to alert her to high-risk cases and did not routinely review or sign off on assessments or attend relevant meetings. The RD was unaware of the specific high-risk cases and the DT’s practice of signing notes as the dietician.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to implement enhanced barrier precautions (EBP) during wound care for one resident with venous stasis ulcers. During an observed wound care procedure, a registered nurse and a wound technician did not wear gowns as required by facility policy, despite gowns being readily available in the room and signage indicating that EBP was necessary. The staff performed hand hygiene and wore gloves, but omitted the use of gowns. The physician present confirmed the wounds were venous stasis ulcers, which are considered chronic wounds under the facility's EBP policy. When questioned, the registered nurse stated that she believed gowns were only required if the wound was draining, not during all wound care. The unit manager clarified that staff had been in-serviced on EBP and that the policy requires the use of gowns for all wound care involving chronic wounds, regardless of drainage. The failure to follow the established EBP protocol was identified through observation, interview, and review of facility policy and records.
Inaccurate MDS Coding for Weight and Wound Count
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. Specifically, the quarterly assessment recorded the resident's weight as 155 pounds, which was the admission weight, instead of the correct weight of 141 pounds documented seven days prior to the assessment. Additionally, the discharge return anticipated assessment inaccurately documented the number of unstageable wounds as five, while the wound care provider's note indicated there were only four unstageable wounds present at that time. These inaccuracies were confirmed by the MDS Coordinator, who acknowledged the errors in both the weight and wound count coding. The resident involved had a history of peripheral vascular disease, stroke, and diabetes, and was cognitively intact at the time of the assessments. The facility's policy and the RAI manual require accurate and validated assessments, but these requirements were not met in this instance.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide showers as scheduled for two residents who were dependent on staff for activities of daily living, specifically bathing. For one resident with spina bifida, paraplegia, and a urostomy, care plans and physician orders required substantial staff assistance for scheduled showers and documentation of refusals. However, documentation revealed missed showers, lack of proper recording of refusals, and incomplete follow-through on required documentation in both the electronic medical record and on shower sheets. Interviews with staff confirmed that the resident was not consistently offered showers as scheduled, and that refusals were not always documented or reported according to facility policy. For another resident with peripheral vascular disease and multiple wounds, care plans and orders also required total staff assistance for bathing and documentation of refusals. Review of records showed inconsistent documentation of showers and refusals, with several instances where shower sheets were not signed by a nurse and no corresponding nursing progress notes explaining the refusals. Staff interviews indicated that the process for documenting refusals and ensuring nurse follow-up was not consistently followed, and that some showers or bed baths may not have been offered or properly recorded. Facility policy required that all showers or refusals be documented, including the reason for refusal, interventions taken, and nurse sign-off. The lack of consistent documentation and failure to follow established procedures for offering and recording showers and refusals resulted in these two residents not receiving scheduled showers or appropriate documentation, placing them at risk for skin breakdown and diminished quality of life.
Lack of RD Oversight in Nutritional Management
Penalty
Summary
The facility failed to ensure proper oversight and supervision by the Registered Dietician (RD) of the Dietary Technician (DT) for a resident who was at increased risk for unintended weight loss. The resident, who had a history of stroke with left side paralysis, difficulty swallowing, and dementia, was admitted with severe cognitive impairment and total dependence for feeding. The care plan identified the need for a mechanically modified diet, assistance with meals, and supervision due to pocketing food. Despite these interventions, the resident's oral intake remained less than 50%, and she refused oral nutritional supplements, with fortified foods being added as an alternative. The resident experienced a significant weight loss of 6.7 pounds in one week. Observations revealed that the resident was often left without staff assistance at mealtimes, resulting in minimal food consumption. Interviews with staff indicated that the DT, rather than the RD, completed the admission nutritional assessment and made changes to the resident's care plan without the RD's awareness. The RD confirmed she was not informed about the resident's high-risk status or the weight loss, and that she typically reviews high-risk assessments with the DT but was not involved in this case. This lack of RD oversight and communication contributed to the failure to maintain the resident's nutritional status.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nurse Aide (CNA). The incident involved CNA D intentionally moving the resident's call light out of reach and closing the door, which deprived the resident of the ability to summon assistance. This action was reported by CNA D to RN E, but RN E did not report the incident to the Nursing Home Administrator (NHA), allowing CNA D to continue working for three additional shifts before being suspended. The resident involved was readmitted to the facility with diagnoses including traumatic spinal cord dysfunction and quadriplegia, making them dependent on staff for all activities of daily living. The resident's care plan emphasized the importance of having the call light within reach. Despite this, CNA D removed the call light after an argument with the resident, leaving them in the dark and unable to communicate their needs. The resident reported feeling better and safer after the call light was returned by RN E. The facility's policies required immediate reporting of abuse allegations to the Administrator and other appropriate agencies, but RN E failed to do so, believing the situation was handled. This oversight allowed CNA D to remain in the facility, posing a potential risk to the resident. The failure to report and address the abuse promptly led to a finding of immediate jeopardy, highlighting a significant deficiency in the facility's handling of abuse allegations.
Removal Plan
- RN E was given a verbal education on abuse policy, reporting compliance, and to always contact the Administrator if there are any allegations of abuse.
- CNA D was removed from resident care prior to the start of shift.
- All nursing staff will be re-educated on abuse, neglect and misappropriation policy education; abuse reporting and compliance policy; resident call light accessibility.
- Administrator or designee to orient all new staff on the abuse reporting policy and how to contact those individuals.
- Director of Nursing or designee to provide education on abuse reporting policy monthly at staff meetings.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the Administrator, as required by their policy. This failure placed all residents at risk because the accused staff member, CNA D, was allowed to continue working with residents for three additional shifts before the incident was reported to the administration. The incident involved CNA D refusing to provide care to a resident, R1, who has a traumatic spinal cord dysfunction and quadriplegia, and is dependent on staff for all activities of daily living. CNA D removed R1's puff-activated call light and shut the resident's door, actions which were reported to RN E but not escalated further. RN E, upon learning of the incident, instructed CNA D not to return to R1's room and returned the call light to R1. However, RN E did not report the incident to the Nursing Home Administrator or any other authority, believing she had handled the situation. As a result, the incident was not reported to the State Survey Agency until several days later, and an investigation did not begin until after this delay. The facility's policy mandates that such allegations be reported immediately, but this protocol was not followed, leading to a significant delay in addressing the situation.
Unlicensed Staff Administering Medications
Penalty
Summary
The facility failed to ensure that only licensed nursing staff administered medications to residents on the Heritage unit, which led to a deficiency. The facility's policy on medication administration, revised in May 2022, states that medications should be administered by licensed nurses or other legally authorized staff. However, during a holiday when several nurses called in sick, the Director of Nursing (DON) instructed Certified Nursing Aides (CNAs) to pass medications to residents, a task outside their scope of practice. Interviews with staff revealed that CNAs were asked to participate in a practice referred to as 'push and pass,' where a Registered Nurse (RN) would dispense medications into a cup, and the CNA would then deliver the medications to the residents. This occurred under the direct supervision of the RN, who maintained line of sight. Despite this supervision, the practice was not in compliance with state regulations, which only allow CNAs with specific medication aide training and designation to pass medications. The Nursing Home Administrator (NHA) was aware of the situation and deferred to the DON's decision to allow CNAs to pass medications. The DON justified the decision by citing the absence of nurses and the need to ensure timely medication administration. However, this action was outside the permissible delegation scope, as confirmed by the Pharmacy Practice Consultant with the Department of Health Services, who outlined the specific conditions under which CNAs could administer medications.
Verbal Abuse by Staff Members
Penalty
Summary
The facility failed to protect three residents from verbal abuse by two staff members, which placed them at risk of psychosocial harm. The first incident involved a CNA who was verbally abusive to two residents during mealtime. One resident, who was severely cognitively impaired, was threatened by the CNA for not eating properly, while another resident, who was cognitively intact, was forced to eat and ridiculed for her eating habits, causing her to cry. A fellow CNA witnessed the abuse but did not intervene directly, instead reporting it to the nurse and the Nursing Home Administrator. In a separate incident, another CNA made racially insensitive remarks while providing ostomy care to a resident. The resident, who was cognitively intact, did not recall the specific comments but remembered the CNA's frustration during the care process. An LPN present during the incident reported the remarks to the Nursing Home Administrator, leading to the CNA being placed on administrative leave. The Director of Nursing noted that the CNA involved in the first incident was a new employee, while the CNA in the second incident resigned after being placed on leave. The Nursing Home Administrator confirmed that verbal abuse was substantiated in both cases, highlighting a failure in the facility's policy to prevent and prohibit abuse, neglect, and exploitation of residents.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with 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.
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.
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 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.
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.
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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