Christian Community Home Of Osceola, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Osceola, Wisconsin.
- Location
- 2650 65th Ave, Osceola, Wisconsin 54020
- CMS Provider Number
- 525706
- Inspections on file
- 16
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Christian Community Home Of Osceola, Inc during CMS and state inspections, most recent first.
Surveyors found that food items in the kitchen were not consistently labeled with open or use-by dates, and some expired foods were not discarded as required. Additionally, a cook's personal beverages were stored on the food prep table near food being served, contrary to facility policy. Staff interviews confirmed lapses in following food safety and personal hygiene protocols.
The facility did not maintain an effective infection prevention and control program, with incomplete infection surveillance logs and multiple instances of improper hand hygiene by staff. An LPN handled medications with bare hands and failed to sanitize before administering them to two residents, while a CNA provided care to two residents without performing hand hygiene before or after glove use. Residents with indwelling catheters received care without proper glove changes or hand hygiene, increasing the risk of infection transmission.
The facility did not assess or document the appropriate size and fit of mechanical lift slings for residents requiring assistance with transfers, leaving CNAs to select sling sizes without guidance or documented assessments. Multiple residents with significant mobility needs were transferred using slings that may not have been properly fitted, and staff interviews revealed confusion about responsibility for determining sling size. The lack of assessment and documentation led to inconsistent and potentially unsafe transfer practices.
Surveyors found that multiple medications, including Lorazepam, Amoxicillin, and Morphine Sulfate, were stored without proper labeling or were expired, and that prescribed Nystatin powder was left unattended at a bedside without a self-administration assessment. Staff interviews confirmed that required labeling and storage procedures were not consistently followed, and monthly pharmacy reviews had previously identified similar issues.
A resident with multiple complex diagnoses, including diabetes, repeatedly refused prescribed insulin, and the nurse documented the refusals but did not notify the physician as required. The DON confirmed that facility policy requires provider notification for each insulin refusal to allow for medication reassessment.
A contracted RN began working without a completed background check, including BID, DOJ, or IBIS, in violation of facility policy requiring screening for abuse, neglect, and misappropriation history prior to employment. This lapse was identified during a review of staff records and confirmed by the NHA.
A CNA applied prescribed Nystatin powder to a resident's skin folds instead of a nurse, as required by facility policy and physician order. The resident, who had multiple complex medical conditions, received the medication from the CNA after a shower, and both the CNA and RN confirmed this was routine practice. The DON stated that only nurses should administer prescribed medications unless the resident is assessed for self-administration, which had not occurred in this case.
A resident with significant physical limitations and a history of stroke experienced repeated delays in receiving assistance with toileting, waiting up to 36 minutes after requesting help. The resident, who required two staff and a mechanical lift for transfers, was left waiting due to staff breaks and failure to seek additional help, resulting in incontinence and emotional distress. The resident and family reported that such delays were common, and the DON confirmed that staff are expected to respond to requests within five minutes.
A registered nurse did not complete a required pre-treatment lung assessment with a stethoscope before administering a nebulizer treatment to a resident with multiple medical conditions, as mandated by facility policy. The nurse acknowledged the omission, and the DON confirmed that both pre- and post-treatment assessments are expected for respiratory therapy.
The facility did not notify the State Long-Term Care Ombudsman when two residents were either transferred to a hospital or discharged to another care setting. One resident with moderate cognitive impairment was hospitalized, and another with multiple chronic conditions was discharged to assisted living, but neither event was reported to the Ombudsman as required. The facility's process only included hospital readmissions, omitting other transfers and discharges.
The facility failed to prevent foodborne illness by allowing a cook to handle ready-to-eat foods with contaminated gloves, serving food at unsafe temperatures, not ensuring proper dish sanitization, and improperly labeling and storing food items. Personal belongings were also found on the food prep table.
The facility failed to maintain an effective infection prevention and control program, including a water management plan and infection surveillance. Maintenance and flushing records were not documented, and infection surveillance logs for residents and staff were incomplete or missing. The DON/IC admitted to creating logs only after the surveyor's request, and there was a lack of systematic infection control measures and documentation.
The facility failed to establish an effective Antibiotic Stewardship Program, lacking proper documentation and monitoring of antibiotic use and infection surveillance. The DON admitted reliance on PA orders without proper documentation, and policies were outdated.
The facility failed to develop and implement comprehensive individualized care plans for three residents, leading to deficiencies in fall prevention and pain management. One resident experienced multiple falls without a proper care plan, another had pain and anticoagulant use not initially included in their care plan, and a third had a fall without updated interventions in their care plan.
A resident developed an unavoidable stage 2 pressure injury, and the Director of Nursing did not follow proper infection control procedures during wound care. The DON failed to change gloves and perform hand hygiene between steps, despite acknowledging the need for these practices.
The facility failed to ensure a safe environment for two residents, leading to repeated falls. Despite high fall risk assessments, care plans were not consistently updated with fall prevention interventions. Observations and staff interviews confirmed that fall interventions were not followed, contributing to the residents' repeated falls.
A resident with multiple medical conditions, including recent knee surgery, was repeatedly given a lower dose of Oxycodone than prescribed for higher pain levels. Interviews with staff confirmed the discrepancy, although the resident's pain was reported to be controlled.
A resident did not receive proper pharmaceutical services when an LPN failed to prime an insulin pen before administering insulin. The facility's policy requires priming the pen with 2 units to remove air bubbles, but this step was skipped, as confirmed by the LPN and DON.
The facility failed to ensure that a resident was given psychotropic drugs only when necessary and did not limit PRN orders for these drugs to 14 days. The resident was prescribed antipsychotic medication without a specific condition diagnosed or targeted behavior documentation, and the medication was administered without a stop date ordered. The facility's Behavioral Intervention and Management Program meetings had not been conducted since 2022, leading to a lack of proper monitoring and documentation.
The facility failed to ensure proper storage and labeling of medications, with multiple observations of unlocked medication carts and unlabeled opened medications. Despite clear policies and monthly pharmacy reviews, these deficiencies were not corrected in a timely manner.
Improper Food Storage, Labeling, and Personal Item Handling in Kitchen
Penalty
Summary
Surveyors identified that the facility failed to prepare, distribute, and serve food in a manner that prevents foodborne illness for all residents reviewed. During a kitchen inspection, multiple food items in the cooler and refrigerators were found either unlabeled or labeled incorrectly regarding open or use-by dates. Examples included pulled pork, red Jello, crushed pineapple, tomato sauce, and ham salad, some of which were expired or lacked proper labeling. Staff interviews confirmed that the labeling and discarding of expired foods had not been consistently performed, particularly over the weekend. Additionally, personal beverages belonging to a cook were observed on the food preparation table near items being served for lunch. The facility's policies require that personal items and beverages be stored away from food preparation areas, but staff were unclear about appropriate storage locations for personal beverages. The Dietary Manager confirmed that the observed practices did not meet facility expectations for food safety and personal hygiene.
Infection Control Program Deficiencies and Hand Hygiene Failures
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance and improper hand hygiene practices. Infection surveillance logs were missing critical data, such as the type and location of outbreaks, testing performed, well dates for residents and staff, and details regarding isolation precautions. During an influenza outbreak, the facility did not document essential information needed to monitor and prevent the spread of infection. The Nursing Home Administrator acknowledged that the facility relied on a county-provided spreadsheet and was unaware that additional data was required for adequate infection monitoring. Staff infection tracking was also inconsistent, as staff did not always complete required screening forms. Direct care observations revealed multiple instances of improper hand hygiene and infection control breaches. An LPN was observed handling medications with bare hands, failing to sanitize hands before touching pills, and returning a dropped pill from a contaminated surface to a resident's medication cup. The LPN admitted awareness of proper procedures but did not follow them due to concerns about medication costs. Additionally, a CNA was observed performing resident care without completing hand hygiene before donning gloves, after removing gloves, or between tasks, and used contaminated gloves to touch clean surfaces and equipment. The CNA claimed to use hand gel frequently, but surveyors did not observe any hand hygiene during care. Residents with complex medical needs, such as those with indwelling catheters, were also affected by these lapses. One resident with a suprapubic catheter and nephrostomy tube received care from staff who failed to change gloves or perform hand hygiene when moving between clean and dirty areas during catheter care and dressing changes. During a catheter change, an LPN switched from sterile to non-sterile gloves without hand hygiene and manipulated the catheter, later acknowledging the omission. These failures in infection control practices had the potential to affect all residents in the facility.
Failure to Assess and Document Proper Sling Size for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not assess residents for the safe use of the EZ sit to stand lift for five residents, nor did it have a procedure in place to assess and document the appropriate size and fit of the EZ Way Smart Stand mechanical lift slings for each resident. Certified Nursing Assistants (CNAs) were left to determine sling size based on their own judgment, without guidance from care plans or CNA care guides, and without documented assessments of residents' torso circumference as required by manufacturer guidelines. Multiple residents with significant mobility impairments, including those with a history of stroke, hemiplegia, Parkinson's disease, and other conditions requiring substantial assistance with transfers, were observed being transferred using the EZ sit to stand lift. In all cases, there was no documentation or care plan specifying the correct sling size, and no evidence that an assessment of torso circumference had been completed. During observations, CNAs selected slings based on availability and their perception of resident size, sometimes discussing among themselves which sling to use. In one instance, a resident was observed hanging from her armpits during a transfer, indicating improper fit or use of the sling. Interviews with staff, including CNAs, an Occupational Therapist, an LPN, and the Director of Nursing, revealed a lack of clarity and responsibility regarding who was supposed to determine and document the correct sling size for each resident. The Director of Nursing acknowledged that sling size was not listed on any care guide and was unsure who was responsible for assigning sling sizes. Inventory checks showed limited availability of sling sizes, and staff reported that slings were not kept in residents' rooms and would need to be washed before reuse, potentially delaying care. The lack of assessment, documentation, and clear procedures led to inconsistent and potentially unsafe use of mechanical lift slings for residents requiring assistance with transfers.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices for five residents. In the medication storage room, two opened bottles of Lorazepam for two residents were found without labels indicating the date opened or expiration, making it unclear when they should be discarded. Additionally, an opened and expired bottle of Amoxicillin for another resident was found in the refrigerator, with the expiration date clearly passed. On a medication cart, a bottle of Morphine Sulfate liquid for a resident was opened and unlabeled, with no indication of the date it was first used or when it should expire. Staff interviews confirmed that the expected practice is to label medications with the date opened, but this was not consistently followed. Further observations revealed that prescribed Nystatin powder was left unattended on a resident's bedside table. The resident reported that CNAs applied the powder after showers, but there was no assessment found for self-administration of medications, which is required by facility policy for bedside medication storage. The facility's policies require that all medications be labeled with the date opened and expiration, and that expired medications be promptly removed and destroyed. Monthly pharmacy reviews had previously identified similar issues, including undated and expired medications, but these problems persisted at the time of the survey. Interviews with nursing staff and the Director of Nursing confirmed that the facility's expectations were not met regarding medication labeling and storage. Nurses acknowledged that medications should be labeled upon opening and that expired medications should be discarded immediately. The Director of Nursing stated that nurses on each shift are responsible for monitoring medication refrigerators for expired drugs, and that pharmacy reviews are conducted monthly. However, the ongoing presence of unlabeled and expired medications, as well as improper bedside storage without proper assessment, demonstrated a failure to adhere to established policies and professional standards.
Failure to Notify Physician of Insulin Refusal
Penalty
Summary
A deficiency was identified when a nurse failed to notify the physician on call regarding a resident's repeated refusal of prescribed insulin. The resident, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure, had a physician order for 6 units of insulin aspart to be administered subcutaneously before meals, unless blood glucose was below 100. During observation, the nurse checked the resident's blood glucose, found it to be 169, and noted that the resident had been refusing insulin due to previous hypoglycemic episodes. The nurse documented the refusal and monitored the resident but did not notify the physician of the refusal. Upon interview, the nurse acknowledged that physician notification should occur when insulin is refused, as this could prompt a reassessment of the medication order. Review of the resident's progress notes confirmed that the provider was not contacted regarding the refusal. The Director of Nursing confirmed that the facility's expectation is for nurses to notify the provider every time insulin is refused, to allow for potential adjustment or discontinuation of the medication.
Failure to Screen Contracted RN for Abuse and Neglect History
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of employees for a prior history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, a review of eight staff members' Background Information Disclosures (BID) revealed that one registered nurse (RN), who was a contracted staff member, did not have a completed BID, Department of Justice (DOJ) check, or Integrated Background Information System (IBIS) check prior to starting work. The facility's policy requires that all new employees have their background checked before working with residents, but this process was not followed for the contracted RN. The omission was discovered during a surveyor's review and confirmed in an interview with the Nursing Home Administrator, who acknowledged that the background check had not been completed at the time of hire.
CNA Administers Prescribed Medication Instead of Nurse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) administered a prescribed medication, Nystatin powder, to a resident's skin folds, rather than a licensed nurse as required. The resident, who had multiple diagnoses including type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure, had a physician's order for Nystatin powder to be applied topically three times a day for a candida yeast skin infection. During a survey, the prescribed Nystatin powder was observed on the resident's bedside table, and both the resident and CNA confirmed that the CNA applied the medication after the resident's shower that morning. Further interviews revealed that the CNA routinely applied the Nystatin powder to the resident's groin folds, especially on shower days, due to difficulty locating a nurse. The registered nurse (RN) on the unit acknowledged that CNAs often applied the medication, and the director of nursing (DON) confirmed that it was not acceptable for CNAs to administer prescribed medications, stating that only nurses should do so unless the resident has been assessed and deemed capable of self-administration. The storage of the medication at the bedside was also discussed, with the DON indicating it was only appropriate if the resident could self-administer, which had not been established.
Delayed Assistance with Toileting and Repositioning
Penalty
Summary
A resident with a history of stroke, hemiplegia, hemiparesis, partial digestive tract removal, recurrent urinary tract infections, and vascular dementia required substantial assistance for repositioning and toileting. The resident was cognitively intact and able to communicate needs, as documented in the MDS assessment. On two observed occasions, the resident requested assistance to use the bathroom and experienced significant delays—waiting 36 minutes and 30 minutes, respectively—before being assisted by staff. During the first incident, the resident required a clothing change due to incontinence and expressed feelings of embarrassment and being a burden. The care plan indicated the resident should receive necessary assistance with toileting upon request. Staff interviews revealed that delays occurred because two staff members were required for transfers using a mechanical lift, and one CNA was on break during the incident. The CNA did not seek additional help from other available staff or use the walkie to request assistance, despite this being an available option. The DON stated that the expectation is to respond to resident requests within five minutes and that staff should check on residents' needs before going on break. The resident and family members reported that long waits for assistance were a recurring issue, and the resident was on a waiting list for another facility due to dissatisfaction with care.
Failure to Perform Pre-Respiratory Assessment Prior to Nebulizer Treatment
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to perform a pre-respiratory assessment prior to administering a nebulizer treatment to a resident. According to facility policy, a pre-treatment lung assessment, including auscultation of breath sounds with a stethoscope, is required before administering nebulizer therapy. During the observed administration, the RN applied gloves and began the nebulizer treatment without first listening to the resident's lung sounds. The RN acknowledged this omission when questioned and stated that the assessment would be performed after the treatment. The resident involved had been admitted with diagnoses including iron deficiency anemia secondary to blood loss, bipolar disorder, and major depressive disorder, and had a physician's order for albuterol sulfate nebulizer treatments for cough. The Director of Nursing confirmed that the expectation is for nurses to complete both pre- and post-treatment lung assessments using a stethoscope to monitor the effectiveness of the therapy. The failure to perform the required pre-treatment assessment constituted a deviation from facility policy and standard practice.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers and discharges for two residents out of a sample of twelve. Specifically, one resident with moderate cognitive impairment and an activated Power of Attorney for Health Care was transferred to the hospital due to urinary retention and constipation, but the Ombudsman was not notified of this transfer. Documentation showed that a notice of bed hold and reason for transfer was signed by the POAHC, but the required Ombudsman notification was not completed. Another resident, who had diagnoses including cerebral infarction, chronic headaches, dizziness, and chronic kidney disease, was discharged to an assisted living home without the Ombudsman being notified. Review of the facility's records revealed that the list provided to the Ombudsman only included residents who were readmitted from the hospital and did not account for those who were transferred, discharged, or had passed away. The Nursing Home Administrator confirmed that the Social Worker was responsible for notifications but only sent information about hospital readmissions.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. The cook was observed touching ready-to-eat foods with contaminated gloves while serving meals. Additionally, the facility failed to ensure that foods were served at safe temperatures, as evidenced by the pork tenderloin on the hot steam table being served at 132.6 degrees Fahrenheit, which is below the required 135 degrees Fahrenheit. The dietary manager confirmed that the pork tenderloin should not have been served at this temperature, and temperature logs were not maintained for the point of service checks. The facility also did not ensure proper sanitization of dishes. The surveyor observed that the dishwasher's temperature gauge read below the required 120 degrees Fahrenheit during multiple cycles, and the cook did not check the temperature or use chemical strips for proper sanitization. The dietary manager confirmed that the dishwasher is a low-temperature chemical sanitization system and that the cook should have checked the temperatures and chemical ratios before completing the dishwashing cycles. Furthermore, the kitchen cooler contained various foods in cups that were not labeled with open or use-by dates. Items such as butter, vanilla pudding, leftover meatloaf, and bran muffins were found without proper labeling or past their use-by dates. Additionally, personal belongings of a dietary aide were found on the food prep table, which is against the facility's policy. The dietary manager acknowledged these issues and indicated that personal belongings should be kept in the employee break room and not on the kitchen prep table.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which included a water management program and infection surveillance. The facility did not document maintenance, inspections, or flushing of areas of concern as required by their Water Management Plan. Interviews with the Nursing Home Administrator and Director of Maintenance revealed that while they were aware of the need for flushing, no records were kept, and a documentation sheet had been created but not used. Room occupancy records showed multiple instances of rooms being left vacant for extended periods without proper flushing, increasing the risk of Legionnaires' disease and other waterborne infections. The facility's infection surveillance and treatment program were also found to be inadequate. The Director of Nursing/Infection Control (DON/IC) was unable to provide complete and accurate infection surveillance logs for residents and staff. The DON/IC admitted to creating monthly line lists only after the surveyor's request and acknowledged that infection surveillance had not been properly maintained. The infection logs provided were incomplete and lacked necessary details such as signs and symptoms, testing results, and follow-up care. The DON/IC also indicated that the process for tracking and treating infections was not well-established, and there was a lack of documentation and coordination with the interdisciplinary team. Staff infection surveillance was similarly deficient. The Human Resources Coordinator tracked staff call-ins but did not maintain comprehensive records or a plan of action to prevent the spread of infections. The DON/IC did not document staff infection surveillance or follow-up actions, relying instead on verbal communication and ad-hoc decisions. This lack of systematic infection control measures and documentation put all residents and staff at risk of communicable diseases and infections.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility did not establish an Infection Prevention and Control Program (IPCP) that includes an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor antibiotic use. This deficiency has the potential to affect all 33 residents in the building who may utilize antibiotics. The facility failed to ensure the standard of practice for infection surveillance and treatment, and McGeer's criteria were not utilized in the facility's antibiotic stewardship program. The facility's policy on Nosocomial Infection Surveillance/Antibiotic Stewardship Program was not followed, as evidenced by the lack of documentation and monitoring of antibiotic use and infection surveillance logs from the specified dates. The surveyor reviewed the resident infection surveillance line lists and found that the logs did not include necessary details such as signs and symptoms of infection, start date of infection, start date of isolation, start date of antibiotics, appropriate lab culture results, hospitalizations, or well dates. Additionally, the Director of Nursing (DON) admitted that the facility relies solely on the Physician Assistant's orders without proper documentation or diagnostic tests. The antibiotic stewardship committee only meets annually, and the policies were last updated in 2022, indicating that they were not up to date. No further documentation was provided to address the expired policies or the deficiencies in the antibiotic stewardship process.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive individualized care plans for three residents, leading to deficiencies in their care. Resident R4, admitted for end-of-life hospice care, had a high fall risk but experienced 25 falls over a two-month period without a comprehensive care plan addressing fall prevention. Despite having interventions listed on a Nursing Assistant Assignment Sheet, these were not observed in practice, and no comprehensive care plan was found in R4's records. Resident R17, with multiple diagnoses including cognitive communication deficit and vascular dementia, had frequent moderate pain and was on anticoagulant therapy. However, R17's care plan did not initially include pain management or anticoagulant use. These care plans were only added after the surveyor requested them. Interviews with R17 and staff confirmed that pain management was being provided, but the care plan was not updated to reflect this until after the surveyor's inquiry. Resident R180 experienced a fall and was sent to the emergency room, but no injury was sustained. Despite an IDT review recommending a perimeter mattress, the comprehensive care plan did not include any interventions related to fall prevention. The updated interventions from the IDT review were not found in the comprehensive care plan, indicating a failure to document and implement necessary care plan updates for fall prevention.
Failure to Follow Proper Infection Control Procedures During Wound Care
Penalty
Summary
The facility did not provide care consistent with professional standards to prevent the development of a pressure injury for a resident. The resident, who had diagnoses including pressure ulcer, dementia, multiple sclerosis, neurogenic bowel, and quadriplegia, developed an unavoidable stage 2 pressure injury while at the facility. The resident's care plan included interventions such as daily skin observation, pressure-relieving cushions and mattresses, and turning and repositioning every 2-3 hours. Despite these measures, the resident developed a stage 2 pressure injury in the ischial area, which was first noted on 03/15/24 and measured 1.5 cm x 1.4 cm x 0.3 cm. The most recent measurement on 04/03/24 indicated the wound was 1 cm x 0.9 cm x 0.5 cm. Weekly assessments and physician notifications were conducted, and wound care orders were updated accordingly. During an observation on 04/04/24, the Director of Nursing (DON) performed wound care on the resident but did not follow proper infection control procedures. The DON did not change gloves or perform hand hygiene between steps of the wound care process. Specifically, the DON removed the old dressing, measured the wound, and cleaned the wound without changing gloves or performing hand hygiene. The DON then used the same contaminated gloves to handle wound care supplies and apply new dressings. When interviewed, the DON acknowledged that hand hygiene should have been performed between glove changes and after cleaning the wound, but it was not done during the observed wound care session.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility did not ensure that the resident's environment remained as free of accident hazards as possible for two residents. Resident R4, who was admitted for end-of-life hospice care, experienced 25 falls between October 12, 2023, and December 23, 2023. Despite multiple fall risk assessments indicating a high risk for falls, the facility failed to consistently document and implement fall prevention interventions in R4's care plan. Observations during the survey revealed that fall interventions were not being followed, and there was no documentation supporting that psychotropic medication was considered a potential cause of falls prior to its discontinuation on November 27, 2023. The Director of Nursing confirmed that fall interventions had not been added to R4's plan of care despite the high number of falls and the use of lorazepam, which increased the fall risk. Resident R5, who had multiple diagnoses including cognitive communication deficit and vascular dementia, also experienced repeated falls without appropriate updates to the care plan. R5's fall risk assessments consistently indicated a high risk for falls, yet the care plan was not revised following falls on November 1, 2023, December 15, 2023, January 16, 2024, January 19, 2024, and February 21, 2024. Post-fall assessments documented the falls and immediate interventions, but the care plan interventions were not updated to reflect these incidents. Interviews with staff revealed that the care plan was not promptly updated with new fall prevention interventions, and the Certified Nursing Assistant care plan did not include specific fall risk information for R5. The Director of Nursing acknowledged that the care plans for both residents should have been updated immediately after determining fall interventions. The failure to update care plans and implement consistent fall prevention measures contributed to the repeated falls experienced by both residents. This deficiency highlights the facility's lack of adherence to its fall prevention policy and the need for improved documentation and communication among staff to ensure resident safety.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility did not ensure that pain management orders were followed for a resident who required such services. The resident, who had a history of left knee joint replacement surgery, migraine, Parkinson's disease, dementia, cognitive communication deficit, diabetes, poly-osteoarthritis, chronic pain, and low back pain, was prescribed Oxycodone with a dosage based on the pain scale. However, the facility repeatedly administered a lower dose of 2.5 mg instead of the prescribed 5 mg for pain levels of 6-10. This occurred on nine out of eleven occasions, as documented in the Medication Administration Record (MAR). Interviews with the resident, an LPN, and the Director of Nursing (DON) confirmed the discrepancy. The resident reported experiencing pain and receiving pain management through medication, ice packs, and elevation of the knee. The LPN acknowledged that the resident should have received the 5 mg dose for pain levels of 6 and 7, and the DON confirmed that the staff should have administered the correct dosage according to the pain scale. Despite the incorrect dosages, the resident's pain was reported to be controlled at the time of the interviews.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility did not ensure that a resident was provided pharmaceutical services to meet their needs, specifically in the administration of insulin. The deficiency was observed when an LPN failed to prime an insulin glargine pen before administering 7 units of insulin to a resident. According to the facility's policy, the insulin pen should be primed with 2 units to ensure no air bubbles are present before drawing the required dosage. However, the LPN did not follow this procedure during the administration observed by the surveyor. The incident was confirmed through interviews with the LPN and the Director of Nursing (DON). The LPN admitted to not priming the insulin pen before administering the insulin to the resident, despite acknowledging that the usual process involves priming the pen with 2 units. The DON also confirmed that the facility's expectation is for all insulin pens to be primed with 2 units before drawing and administering the required dosage. This failure to follow proper procedure led to the deficiency noted in the report.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Additionally, the facility failed to limit PRN orders for psychotropic drugs to 14 days. This deficiency was observed in the case of a resident (R4) who was admitted for end-of-life hospice care with a terminal prognosis of stage 4 chronic kidney disease and multiple sclerosis. R4 was prescribed antipsychotic medication without a specific condition diagnosed or targeted behavior documentation, and the medication was administered without a stop date ordered. R4's orders included Quetiapine Fumarate and lorazepam, which were administered without proper documentation of targeted behaviors or assessments regarding effectiveness and potential adverse consequences. The resident received PRN lorazepam multiple times in September, October, and November, and was later prescribed haloperidol without a stop date or rationale for continued use. The facility's Director of Nursing (DON) confirmed that the PRN use of Haldol without a stop date was inappropriate and that the facility had not been in compliance with psychotropic medication monitoring. The facility's Behavioral Intervention and Management Program (BIMPS) meetings, which are intended to monitor residents receiving psychotropic medications, had not been conducted since 2022 and were only restarted in January 2024. The DON confirmed that there was no documentation supporting the continued use of the antipsychotic medication, including dosage changes, and that the psychotropic medication was not considered a cause of R4's falls prior to the discontinuation of one of the medications. The lack of proper monitoring and documentation led to the deficiency in ensuring the appropriate use of psychotropic medications for R4.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and did not ensure only authorized personnel had access to medication carts. During the three-day survey, multiple observations were made of medication carts left unlocked when unattended and out of view of staff. Specifically, an LPN was observed multiple times leaving the medication cart unlocked while administering medications and attending to other tasks, despite the facility policy requiring medication carts to be locked when unattended. Additionally, the facility failed to label opened medications with the required open or expiration dates. An open bottle of lorazepam and a vial of Humalog insulin were found without proper labeling in the E-hall medication storage room and medication cart, respectively. The facility's policy and pharmacy recommendations clearly stated that such medications should be labeled with open and use-by dates, but these guidelines were not followed. Interviews with the LPN and DON confirmed that the expectation was for all opened medications to be labeled and for medication carts to be locked when unattended. Despite monthly pharmacy reviews identifying these issues, the deficiencies were not corrected in a timely manner. The DON indicated that it was the responsibility of the nurse on duty to address the pharmacy's recommendations, but this was not consistently done, leading to repeated deficiencies in medication storage and labeling practices.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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