Complete Care At Care Age
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookfield, Wisconsin.
- Location
- 1755 N. Barker Rd., Brookfield, Wisconsin 53045
- CMS Provider Number
- 525519
- Inspections on file
- 26
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Care Age during CMS and state inspections, most recent first.
Staff delivered meal trays with uncovered desserts and beverages to residents eating in their rooms, contrary to facility policy requiring food and drinks to be covered during transport. Multiple staff, including CNAs and RNs, were observed preparing and carrying uncovered items down hallways to residents, potentially affecting a significant portion of the facility's population.
A resident with a history of falls and osteoporosis was transferred by a single CNA using a sit-to-stand lift, contrary to her care plan requiring two staff. The lift malfunctioned, resulting in the resident being left in a compromised position and subsequently sustaining a hip fracture. Staff failed to promptly report the incident, did not perform or document a thorough RN assessment, omitted vital signs, and did not communicate the full details to the provider, leading to delayed medical intervention.
Three residents with or at risk for pressure injuries did not receive consistent and necessary interventions, such as offloading boots and regular turning and repositioning, as required by their care plans. Staff were observed not following prescribed protocols, documentation was incomplete or missing, and timely wound assessments were not performed, resulting in the development and worsening of pressure injuries.
A resident who required a two-person assist with a sit-to-stand lift was transferred by a single CNA, resulting in a fall and a right femoral fracture. The incident was not promptly reported or assessed according to facility policy. Additionally, staff charged a motorized wheelchair in a resident's room and electric patient lifts in hallways, contrary to facility policies and safety recommendations.
Surveyors identified multiple deficiencies in food safety and sanitation, including lack of proper monitoring of the chemical dishwasher's sanitizing concentration, staff not wearing required hair or beard restraints in food prep areas, and improper labeling and dating of opened or expired food items. These failures had the potential to affect all residents in the facility.
Multiple residents reported that their meals, especially meat dishes, were too tough to chew and often served cold or lukewarm, particularly when delivered to rooms. Surveyors found food temperatures below required standards for hot foods and above for cold items, and observed residents struggling to eat the provided meals. Staff cited a shortage of heat-retaining equipment and improper cooking methods as contributing factors to the deficiency.
Staff failed to consistently perform proper hand hygiene during wound care and medication administration for several residents. In multiple cases, a nurse practitioner and LPNs did not cleanse hands after removing gloves and before donning new gloves or after handling contaminated items, contrary to facility policy. These lapses were observed during wound care for residents with pressure ulcers and during blood glucose testing, with staff confirming in interviews that correct procedures were not followed.
Two residents with indwelling catheters did not receive proper care to prevent UTIs, as one had a catheter bag in contact with the floor and another received catheter/peri care from a CNA who failed to perform hand hygiene between glove changes and mixed clean and soiled washcloths in the same bags, contrary to facility policy and infection control standards.
Three residents were repeatedly served foods they disliked or could not safely consume, despite their preferences and dietary restrictions being documented. One resident with malnutrition and no teeth was given tough meats and vegetables, another with Crohn's disease received restricted vegetables, and a third continued to receive gravy despite a documented dislike. These failures were observed and confirmed through interviews and record reviews, showing a lack of adherence to resident food preferences and dietary needs.
The facility did not ensure that residents were clinically assessed and approved for self-administration of medications, resulting in multiple instances where medications were left at bedside without proper assessment or physician orders. In several cases, medications were left out for extended periods, and required nurse follow-up was not performed, contrary to facility policy and resident care plans.
Three residents prescribed melatonin for sleep issues did not have required sleep assessments or sleep monitoring documented, despite facility policy mandating such evaluations for psychotropic medication use. The DON confirmed that sleep assessments and monitoring were not routinely performed for residents receiving sleep aids.
Two residents experienced significant medication errors when one did not receive prescribed evening doses of Carbidopa-Levodopa for Parkinson's Disease, and another missed a scheduled dose of IV Meropenem for a wound infection. In both cases, staff confirmed the omissions, and facility policy was not followed regarding medication administration and documentation.
The facility failed to provide adequate pharmaceutical services, as staff did not consistently document medication administration times immediately after administering narcotic pain medications to residents. This led to potential risks of medication errors due to late documentation, with some instances of documentation occurring hours after administration. Interviews with staff revealed that while the policy required immediate documentation, delays occurred due to various reasons, highlighting a deficiency in adherence to the facility's policy and state regulations.
A resident alleged that a CNA caused a skin tear by grabbing her arm, but the facility failed to report this abuse allegation to the State agency within the required timeframe. The incident was initially reported as a skin tear from removing a sweatshirt, and the specific abuse claim was not communicated to the NHA or State agency until two days later, despite facility policy requiring immediate reporting.
A resident's care plan was not revised after an incident where a CNA allegedly caused a skin tear by grabbing the resident's wrist. The resident, who requires substantial assistance for daily activities, had specific preferences and routines that were not documented in the care plan until prompted by a surveyor. The facility's policy mandates care plan revisions upon status changes, which was not followed in this case.
A resident accused a CNA of slapping her, but the LPN did not immediately report the allegation to administration, resulting in the CNA not being removed from the resident care area immediately. The delay in action had the potential to affect 19 residents. The resident involved had severe cognitive impairment and multiple diagnoses.
A resident with severe cognitive impairment accused a CNA of slapping her, but the LPN did not immediately report the allegation to the administration or law enforcement. The incident was only reported later in the morning, delaying the necessary investigation and response actions.
The facility failed to address and follow up on grievances discussed during Resident Council meetings, as multiple residents expressed concerns that their issues were not resolved or followed up on. The facility did not have documented grievance forms or resolutions, and Resident Rights and other important information were not reviewed during meetings.
A resident with dementia did not receive a replacement hearing aid after losing the original one. Despite an audiology consult recommending medical clearance for a new hearing aid, the facility failed to obtain the clearance and follow up on the order. Multiple staff members were unaware of the status, leading to the resident being without a hearing aid for an extended period.
A resident with multiple diagnoses, including dementia, was prescribed Seroquel without obtaining consent from the POA or monitoring for side effects until months later, after a surveyor's inquiry. The facility staff acknowledged the oversight and took steps to address it.
Uncovered Food and Beverages Served to Residents in Rooms
Penalty
Summary
Staff failed to serve food and beverages to residents in accordance with professional standards and facility policy, which requires that prepared food be transported in covered containers. Observations revealed that meal trays delivered to residents' rooms contained uncovered dessert items and beverages. Specifically, a resident received a lunch tray with an uncovered bowl of chocolate cake and coffee without a lid, which had been prepared at the nurses' station and carried down the hallway uncovered. During breakfast service, staff were observed pouring beverages such as orange juice, coffee, and milk into cups and glasses at the nurses' station and then transporting them uncovered to residents' rooms. Interviews with the District Dietary Manager confirmed that the expectation is for all food and beverages transported from the cart down the hall to be covered, and that individual beverage containers should be opened and poured in the resident's room. Despite this, multiple staff members, including CNAs, RNs, and other personnel, were observed passing trays with uncovered items to residents in their rooms. The deficiency potentially affected 45 of 67 residents who eat their meals in their rooms.
Failure to Provide Timely Assessment and Communication After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including osteoporosis and a history of falls, experienced a significant change in condition following an incident involving a sit-to-stand lift. The resident, who required two staff for transfers per her care plan, was transferred by a single CNA using the lift. During the transfer, the lift's battery died, resulting in the resident being left in a squatting position with her buttocks on the foot pads of the lift. The CNA, acting alone, attempted to move the resident from the compromised position to her wheelchair and then to bed, without waiting for a nurse assessment. This incident resulted in a hip fracture for the resident. Following the incident, staff failed to follow established protocols and professional standards of practice. The event was not immediately or accurately reported to the oncoming shift or to the resident's provider, and critical details such as the change of plane and the resident ending up on the floor were omitted. There was no thorough or timely RN assessment performed after the incident, despite the resident reporting escalating pain levels (up to 9 out of 10) and visible changes in the appearance and positioning of her leg. Vital signs were not obtained or documented at the time of the incident or during subsequent pain episodes, and changes in the resident's condition, such as internal rotation of the lower extremity, were not recorded in the medical record. Communication breakdowns further contributed to the deficiency. The provider was not informed of the true nature of the incident, which delayed appropriate medical intervention and diagnostic testing. Staff interviews revealed a lack of understanding and adherence to post-fall protocols, including the requirement for RN assessment before moving a resident after a fall or change of plane. Documentation was incomplete and delayed, with late entries and missing assessments, and staff failed to ensure that all relevant information was communicated to the provider and documented in the resident's record.
Failure to Prevent and Manage Pressure Injuries Due to Inconsistent Implementation and Documentation
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services to prevent the development and worsening of pressure injuries (PIs) and to promote healing, as evidenced by the care of three residents. One resident with multiple comorbidities, including dementia, diabetes, and chronic kidney disease, developed an unstageable pressure injury to the right heel. Despite being care planned for bilateral heel boots at all times and regular turning and repositioning, documentation showed inconsistent implementation of these interventions. The resident was observed without required offloading boots while seated in a Broda chair, and staff interviews confirmed a lack of awareness and adherence to the care plan. Additionally, turning and repositioning were not consistently documented, and the facility did not have a policy for this intervention at the time of the deficiency. Another resident, admitted with a pressure injury on the coccyx and identified as at risk for further pressure injuries, developed an unstageable pressure injury on the left heel. The care plan required Prevalon boots at all times except during therapy, but the resident was observed without the boots and with heels in direct contact with the mattress. The Medication Administration Record and Kardex did not reflect the intervention, and staff were unaware of the requirement, indicating a breakdown in communication and care planning. A third resident did not receive a timely assessment of a pressure injury, with five days elapsing before the wound was evaluated. Facility policies required accurate and timely assessment and documentation of pressure injuries, including measurements and wound characteristics, but these were not followed. The deficiencies were substantiated by direct observations, record reviews, and staff interviews, which revealed lapses in implementing and documenting evidence-based interventions for pressure injury prevention and management.
Failure to Prevent Accidents and Ensure Safe Equipment Use
Penalty
Summary
A deficiency occurred when a resident who required a two-person assist with a sit-to-stand lift was transferred by a single CNA, contrary to the resident's care plan and facility policy. During the transfer, the lift lost battery power, resulting in the resident being lowered to a squatting position and ultimately sitting on the ground, constituting a change of plane/fall. The CNA then assisted the resident off the floor and into her wheelchair without notifying a nurse or obtaining an RN assessment as required by facility policy. The incident was not immediately reported to the floor nurse or oncoming shift, and subsequent communication among staff failed to ensure timely notification and assessment. The resident was later found to have sustained an intertrochanteric right femoral fracture as a result of the incident. The facility's policies required two staff members for all mechanical lift transfers and immediate reporting and assessment following any fall or change of plane. However, the CNA involved in the incident did not follow these protocols, and other staff members who became aware of the event also failed to report it promptly. The facility's investigation revealed that the emergency lowering feature of the lift was not well understood or effectively used by staff, and that staff had not received adequate competency checks or training on lift operation and emergency procedures. Additionally, the facility did not follow its own fall prevention and post-fall assessment protocols, as the resident was moved and transferred multiple times without a nurse's assessment. Further deficiencies were identified regarding the charging of motorized wheelchairs and electric patient lifts. Staff routinely charged a resident's motorized wheelchair in her room, despite facility policy requiring charging in a ventilated, approved area outside resident rooms. Electric patient lifts were observed being charged in hallways, which is inconsistent with safety recommendations for sealed lead acid batteries, as outlined in the manufacturer's safety data sheet. Staff interviews confirmed that these practices were standard, and facility leadership was either unaware of or did not express concern about the safety implications of these charging locations.
Deficient Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, as evidenced by multiple observations and staff interviews. The facility did not have a system in place for manually monitoring the internal concentration of the chemical dishwasher, which is necessary for proper sanitization. Staff were observed to be recording dishwasher temperatures, despite the dishwasher being a chemical sanitizing type, and the temperature logs did not reflect the actual temperatures observed, which were consistently below the required levels. Additionally, the test strips used to monitor chemical concentration were expired, and staff were unsure of the correct procedures for monitoring the dishwasher's effectiveness. Staff in the food preparation areas were observed not wearing appropriate hair restraints, including hairnets and beard nets, despite facility policy requiring all hair to be covered when in the kitchen. Multiple staff members, including dietary managers and aides, were seen in the kitchen and food prep areas with uncovered hair or facial hair while handling food and clean dishes. Staff interviews confirmed a lack of consistent adherence to the hair restraint policy. Food storage practices were also found to be deficient. Surveyors observed multiple instances of opened food items in refrigerators and freezers that were not labeled or dated, as well as food items that were past their expiration or use-by dates. Staff acknowledged that all opened food should be labeled and dated, and that expired food should be discarded, but these practices were not consistently followed. These deficiencies had the potential to affect all 57 residents residing in the facility.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures, as required by facility policy. Multiple residents reported that their meals, particularly meat dishes, were too tough to chew and often served cold or lukewarm, especially when meals were delivered to resident rooms. Surveyors observed that food temperatures on test trays were below the required threshold for hot foods, with mixed vegetables at 122°F and beef with gravy at 130°F, both below the facility's policy of holding hot foods at 135°F or greater. Cold items, such as milk and cranberry juice, were also served above the required cold holding temperature, with milk at 52.1°F and juice at 51°F, exceeding the policy limit of 41°F or below. Residents with varying cognitive abilities, including those with moderate cognitive impairment and diagnoses such as protein-calorie malnutrition and dementia, voiced concerns about the palatability and temperature of their meals. Several residents indicated that the meat was too tough to chew or swallow, and that hot foods were often served cold, particularly for those eating in their rooms. Surveyors directly observed residents struggling to eat the provided meat, and noted that some residents resorted to bringing in outside food due to dissatisfaction with the facility's meals. Staff interviews revealed that there were operational issues contributing to the deficiency, such as a shortage of heat-retaining cambrio tops and bottoms, resulting in inadequate temperature maintenance during meal delivery. The dietary staff acknowledged that the beef was overcooked and dry due to being cooked in two separate stages, contrary to the recipe instructions. The facility's failure to maintain appropriate food temperatures and palatability affected all sampled and supplemental residents reviewed for food quality, as confirmed by both resident interviews and direct surveyor observations.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement and maintain an effective infection prevention and control program, specifically regarding hand hygiene practices during wound care and medication administration. Staff did not consistently perform hand hygiene as required by facility policy and accepted standards of practice. The facility's own policies state that hand hygiene must be performed after removing gloves and before donning new gloves, as well as after handling contaminated items or performing procedures such as wound care and blood glucose testing. In multiple observed instances, a nurse practitioner performed wound care on two residents with pressure ulcers and failed to perform hand hygiene after removing gloves and before putting on new gloves, despite handling wounds and dressings. The nurse practitioner stated that she only washes hands when leaving the resident's room and believed that removing gloves was sufficient to remove contamination. The Director of Nursing confirmed that hand hygiene should have been performed after glove removal and before donning new gloves, in accordance with facility policy. Additional observations included a LPN performing a blood glucose test and then touching the medication cart without removing gloves or performing hand hygiene, as well as another LPN failing to remove gloves and cleanse hands after removing a wound dressing and before cleansing the wound. This LPN also touched the outside of a contaminated gown with bare hands during PPE removal. Interviews with staff and the Director of Nursing confirmed that these actions were not consistent with facility policy or infection control standards.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
Two residents with indwelling urinary catheters did not receive appropriate care and services to prevent urinary tract infections, as evidenced by direct observations and staff interviews. One resident was observed multiple times with a catheter bag dragging on or resting in contact with the floor while being transported in a wheelchair and during wound care. Multiple staff members, including an LPN, the Nursing Home Administrator, and the Director of Nursing, acknowledged that catheter bags should not be in contact with the floor, in accordance with facility policy. Another resident received catheter and peri care from a CNA who failed to maintain proper infection control practices. The CNA placed soiled washcloths in the same garbage bags as clean washcloths, only separating them by keeping dirty ones in one corner and clean ones in another. The CNA also failed to perform hand hygiene between removing soiled gloves and donning new gloves during the care process, despite facility policy requiring hand hygiene at these points. The CNA later acknowledged that hand hygiene should have been performed and that mixing clean and soiled washcloths could be a risk for cross-contamination. Facility policies reviewed by the surveyor required catheter care every shift, proper hand hygiene before and after glove use, and separation of clean and soiled items to prevent infection. The Director of Nursing confirmed that hand hygiene should be performed after doffing and before donning gloves, and that clean and dirty washcloths should be kept in separate bags. These lapses in infection control and catheter care were observed and confirmed through staff interviews and record review.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated resident preferences and dietary needs for three residents, as evidenced by direct observations, interviews, and record reviews. One resident with moderate cognitive impairment and a history of malnutrition and dysphagia was repeatedly served vegetables and tough meats, despite these being listed as disliked foods on his meal ticket and his inability to chew them. The resident had communicated these preferences to staff and the dietician, but the issue persisted, resulting in the resident refusing meals and expressing frustration over not being heard. Another resident with Crohn's disease and a low residue diet order was served mixed vegetables, including beans, which were specifically restricted on her meal ticket. The resident, who was cognitively intact, reported that she sometimes received foods incompatible with her medical condition, and this was confirmed by observation and staff interview. The care plan for this resident did not specify which foods to avoid or safe alternatives, contributing to the dietary errors. A third resident, who had a documented dislike of gravy and a preference for Cheerios at breakfast, continued to receive gravy on her meals and had to repeatedly request her preferred breakfast cereal. Despite her dislikes being clearly listed on her meal ticket, staff continued to serve her foods she did not want, leading to ongoing frustration. These incidents demonstrate a failure to honor resident food preferences and provide appealing alternatives as required by facility policy and resident rights.
Failure to Assess and Approve Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were clinically assessed and approved for self-administration of medications, as required by policy. In one instance, a resident with diagnoses including generalized anxiety disorder, polyosteoarthritis, and congestive heart failure was observed with a cup of medications left on his bedside table for independent consumption. There was no physician's order, care plan, or assessment indicating that this resident was safe to self-administer medications. Both the LPN and DON confirmed that no assessment or order was in place, despite the resident regularly taking medications independently. Another resident was found with multiple medication containers at bedside and scheduled medications left out for more than one hour, contrary to her self-administration assessment, which only permitted Lactaid at bedside and required nurse follow-up within one hour. Observations revealed that medications, including pills from the previous evening, remained at the bedside and on the floor, and the nurse did not follow up as required. The DON confirmed that only Lactaid should be at bedside and that the nurse failed to ensure timely medication administration and removal of unauthorized medications. A third resident was observed with a Combivent inhaler at bedside on multiple occasions, but there was no assessment completed to determine if self-administration was clinically appropriate. Both the LPN and DON confirmed that this resident had not been assessed for self-administration, and facility policy dictates that medications should not be left at bedside without such an assessment. These findings demonstrate a pattern of noncompliance with the facility's own policy regarding the clinical assessment and approval process for resident self-administration of medications.
Failure to Complete Sleep Assessments and Monitoring for Residents on Melatonin
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented for residents prescribed sleep aids, specifically melatonin. Three residents who were prescribed melatonin for sleep-related issues, such as difficulty sleeping, sleep hygiene, and insomnia, did not have a sleep assessment completed or any sleep monitoring documented in their medical records. This lack of assessment and monitoring was identified through both interview and record review. The facility's policy on the use of psychotropic medications requires a documented clinical rationale for medication use, including an assessment of the resident's condition, evaluation of non-pharmacological approaches, and ongoing documentation of the resident's response to the medication. Despite these policy requirements, the Director of Nursing confirmed that sleep assessments and monitoring were not routinely conducted for residents taking sleep aids, resulting in the absence of necessary documentation and evaluation for the affected residents.
Medication Administration Errors Result in Missed Doses for Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with Parkinson's Disease, who had previously been assessed as unable to self-administer medications due to tremors, did not receive her evening doses of Carbidopa-Levodopa as prescribed. Medications were found on her bedside table and on the floor under her wheelchair, and both the resident and staff confirmed that the evening medications had not been taken. The facility's policy defines omitted medications as a medication error, and staff interviews confirmed that the resident was not supposed to self-administer her medications at this time. In the second case, another resident with a recent surgical procedure and a wound infection did not receive a scheduled dose of intravenous Meropenem, an antibiotic ordered to treat the infection. The medication administration record (MAR) for this resident showed a blank entry for the missed dose, and multiple staff members, including an LPN, the ADON, and the DON, confirmed that a blank on the MAR indicates the medication was not given. There was no documentation to support that the dose was administered as ordered. Both incidents demonstrate a failure to follow physician orders and facility policy regarding medication administration and documentation. The omissions were identified through direct observation, interviews with staff and residents, and review of medical records and facility policies. The facility did not ensure that medications were administered as prescribed or that proper documentation was maintained, resulting in significant medication errors for both residents.
Inadequate Pharmaceutical Services and Documentation Delays
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by the lack of consistent documentation of medication administration times. This deficiency was observed in five residents who had medical doctor orders for narcotic pain medication. Facility staff did not consistently document the administration time of the pain medication directly after administering it, as outlined in the facility policy. This late documentation could result in the duplication of pain medication administration, potentially leading to medication errors. For instance, one resident with a diagnosis of dementia and recent hospitalization for sepsis and fractures had multiple instances where the administration of Oxycodone was documented hours after it was given. In some cases, the delay in documentation was as long as nine hours. Another resident with a diagnosis of infection and inflammatory reaction due to a knee prosthesis had duplicate medical doctor orders for Oxycodone, and staff documented the administration of the medication on both orders, which could cause confusion and the possibility of administering more medication than prescribed. Interviews with facility staff, including LPNs, RNs, and the Director of Nursing, revealed that while the policy required immediate documentation of medication administration, there were instances where documentation was delayed due to staff being pulled away for other tasks or forgetting to document until later. The Director of Nursing acknowledged the issue and expressed concern about the potential for medication errors due to the late documentation. Despite the facility's policy and state regulations requiring immediate documentation, the practice was not consistently followed, leading to the identified deficiency.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R2, within the required timeframe. On December 7, 2024, a skin tear was observed on R2's left wrist, which was initially reported by a CNA to an LPN as occurring while removing R2's sweatshirt. However, R2 later alleged that the skin tear resulted from the CNA grabbing her arm. This allegation was communicated to the Director of Nursing (DON) but was not reported to the State Survey Agency or the Nursing Home Administrator (NHA) until December 9, 2024. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. Despite this policy, the DON did not report the allegation to the State agency, citing the need for further investigation due to R2's history of making accusations against staff. The NHA was not informed of the specific allegation of abuse until two days later, after R2's son contacted the facility. R2, who is cognitively intact with a BIMS score of 13, requires substantial assistance with daily activities and has a history of osteoarthritis, anxiety disorder, and other medical conditions. The failure to report the allegation promptly was attributed to miscommunication and assumptions made by the staff regarding the credibility of R2's claims and the necessity of further investigation before reporting to the appropriate authorities.
Failure to Revise Care Plan After Resident Incident
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R2, following an incident where a CNA allegedly grabbed the resident's wrist, resulting in a skin tear. The incident occurred on December 7, 2024, but the care plan was not updated to reflect the resident's preferences and needs until prompted by a surveyor on January 16, 2025. The facility's policy requires care plans to be reviewed and revised upon a resident's status change, which was not adhered to in this case. R2 has a medical history that includes osteoarthritis, anxiety disorder, hypertension, essential tremor, and depressive disorder. The resident requires substantial assistance for various activities of daily living, including toileting, mobility, and dressing. Despite these needs, the care plan did not initially include specific interventions to address R2's preferences, such as keeping the door open due to claustrophobia and the routine of walking back to bed with a walker after toileting in the evening. The deficiency was identified during a surveyor's observation and interviews with facility staff. The surveyor noted that the care plan lacked details on R2's preferences and routines, which could lead to misunderstandings among staff unfamiliar with the resident's care. The Director of Nursing admitted to delegating the task of updating the care plan but did not follow up to ensure it was completed, resulting in the oversight.
Failure to Immediately Remove CNA After Abuse Allegation
Penalty
Summary
The facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. On 4/2/24, a resident accused a Certified Nursing Assistant (CNA) of slapping her. The CNA reported this to a Licensed Practical Nurse (LPN), who did not immediately report the allegation to administration. As a result, the CNA was not removed from the resident care area immediately and was allowed to work the rest of the shift. This failure to act promptly had the potential to affect 19 residents on the 400 hallway. The facility's policy on Abuse, Neglect, and Exploitation, revised on 09/22/2023, mandates immediate protection of the alleged victim and removal of the accused staff member pending investigation. However, the LPN did not follow this policy, leading to a delay in the removal of the CNA. The Nursing Home Administrator and Director of Nursing confirmed that the CNA was only removed after an interview conducted at 6:35 AM, several hours after the initial allegation at 3:35 AM. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 05, and was diagnosed with COPD, Dementia, Restlessness, Agitation, and a History of Falls.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency. A resident accused a Certified Nursing Assistant (CNA) of slapping her, and the CNA reported this to a Licensed Practical Nurse (LPN). However, the LPN did not immediately report the allegation to the administration, and law enforcement was not contacted to report this reasonable suspicion of a crime. The incident was only reported to the administration later in the morning, delaying the necessary investigation and response actions. The resident involved had a history of severe cognitive impairment, as indicated by a BIMS score of 05, and was admitted with diagnoses including COPD, dementia, restlessness, agitation, and a history of falls. The incident occurred during the night, and the resident continued to express that she had been hit, although no physical injuries were observed. The LPN believed the resident's behavior was consistent with her dementia and did not think anything had happened, which contributed to the delay in reporting the incident. The facility's policy required immediate reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable. Despite this policy, the LPN failed to follow the established procedures, and the administration was not informed until later. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the incident was not reported to the police, as they did not consider it a crime. The DON also noted that the LPN had received individualized abuse training on the day of the incident.
Failure to Address and Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to ensure grievances and recommendations discussed during Resident Council meetings were acted upon promptly and with feedback provided. Multiple residents expressed concerns that their grievances were not resolved or followed up on, as documented in the minutes of several Resident Council meetings. Specific grievances included issues with cleanliness, missing personal items, dietary staff not wearing hair nets, call lights not being answered, and food quality. The facility did not have documented grievance forms addressing these concerns or their resolutions, and there was no follow-up documentation in subsequent meeting minutes. The surveyor reviewed the facility's policy on Resident Council meetings, which mandates that the facility act upon concerns and communicate decisions to the Council. However, the surveyor found that the facility did not adhere to this policy. The Activity Director, who had been in the position for three months, confirmed that Resident Rights, the ombudsman, and how to contact the State Survey Agency were not reviewed during the meetings. The Nursing Home Administrator also confirmed the lack of documentation for resolving concerns from previous months. During interviews, residents with varying levels of cognitive function expressed that their concerns were not addressed or followed up on by the facility staff. The surveyor noted that the facility had recently started a new procedure for addressing concerns but had not yet implemented it effectively. The lack of documented resolutions and follow-up actions for grievances discussed in Resident Council meetings indicates a failure to comply with the facility's own policies and procedures, leading to the deficiency noted in the report.
Failure to Provide Hearing Aid for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain hearing ability. The resident, diagnosed with dementia, had an audiology consult on February 19, 2024, for a lost hearing aid. The consult recommended obtaining medical clearance for a comprehensive evaluation for hearing aids. However, as of March 20, 2024, the medical clearance had not been obtained, and the resident did not have a right hearing aid. The resident's care plan included several interventions related to communication and hearing aid use, but these were not effectively implemented due to the missing hearing aid. Multiple observations by the surveyor on March 18 and 19, 2024, confirmed that the resident was not wearing a hearing aid. Interviews with various staff members, including CNAs, LPNs, and the social worker, revealed a lack of follow-up and communication regarding the resident's hearing aid. The social worker had emailed about the issue on March 1 and March 14 but did not receive any response. The LPNs and the Director of Nursing were unaware of the status of the medical clearance and the hearing aid order, indicating a breakdown in the process of obtaining and following up on the necessary medical consult. The facility's policy stated that all residents should have access to hearing and vision services and receive adaptive equipment as indicated. Despite this policy, the resident's hearing aid was lost, and no effective steps were taken to replace it promptly. The lack of coordination and communication among the staff members contributed to the delay in obtaining the necessary medical clearance and the new hearing aid, resulting in the resident not having the required assistive device for an extended period.
Failure to Obtain Consent and Monitor Side Effects for Psychotropic Medication
Penalty
Summary
The facility did not ensure that potential side effects of psychotropic medications were monitored and consents were provided for a resident (R25) who was prescribed Seroquel. R25, who had diagnoses including a fractured patella, coronary artery disease, muscular dystrophy, anxiety, depression, and dementia, was admitted with moderate cognitive impairment and required substantial assistance with daily activities. On 12/18/2023, R25 received an order for Seroquel 25 mg twice daily for behaviors, but the consent for this medication was not obtained from the activated Power of Attorney (POA) until 3/19/2024, after the surveyor inquired about it. Additionally, no monitoring for potential adverse side effects of the Seroquel was documented until 3/19/2024. The deficiency was identified during a review of R25's medical records and interviews with facility staff. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide a consent form for the use of Seroquel until after the surveyor's request. The Social Worker (SW) indicated that behavior meetings were held regularly to review residents on psychotropic medications, but it was the responsibility of the nurse or nurse manager to obtain consents and put in monitoring orders. The NHA acknowledged the oversight and conducted a facility-wide sweep to ensure all consents for psychotropic medications were obtained after the surveyor brought the issue to their attention.
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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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