Complete Care At Glendale West
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, Wisconsin.
- Location
- 6263 N Green Bay Ave, Glendale, Wisconsin 53209
- CMS Provider Number
- 525547
- Inspections on file
- 28
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Complete Care At Glendale West during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a cognitively intact status was observed with a medication cup containing Tylenol left on the overbed table for self-administration, despite no interdisciplinary team assessment or documentation authorizing self-administration. Staff were unable to provide evidence of the required assessment, and facility policy was not followed.
Three residents dependent on staff for ADLs did not consistently receive scheduled showers, with some only receiving bed baths due to lack of appropriate equipment and incomplete documentation. Staff and leadership confirmed that alternative bathing methods were not provided, and care plans were not updated to reflect actual practices.
A resident with chronic Foley catheter use and hypertension experienced a significant change in condition, including increased pain and lack of urine output, but did not receive timely assessment, documentation, or intervention as required by physician orders and facility policy. Staff failed to document vital signs, pain characteristics, and changes in urinary output, and did not perform a comprehensive evaluation despite clear signs of distress. The resident was later hospitalized with sepsis and acute renal failure due to urinary obstruction.
Staff failed to follow infection control protocols for a resident on enhanced barrier precautions, including not wearing gowns during high-contact care, improper hand hygiene, and allowing a urinary collection bag to rest on the floor. The resident, who required substantial assistance and had an indwelling urinary catheter, was cared for by staff who did not consistently change gloves or wash hands between tasks, increasing the risk of infection transmission.
Several residents were repeatedly observed in gowns rather than regular clothing, both in their rooms and in common areas, despite expressing a preference to be dressed and reporting discomfort. Staff interviews revealed that residents without available clothes were routinely left in gowns, even though donated clothing was available in the facility. The facility did not consistently accommodate residents' preferences for clothing, resulting in a lack of dignity and respect for their individual needs.
Several residents were not provided with or did not sign admission agreements—including consent for treatment, financial information, and resident rights—within a reasonable timeframe. In some cases, residents were discharged or readmitted before receiving this information, and one resident reported missing money without having been informed of the facility's policies for safeguarding belongings. Admissions staff confirmed that there was no set timeline for reviewing these agreements, leading to delays in informing residents of their rights and responsibilities.
Multiple residents were admitted or readmitted without timely completion of baseline care plans, and there was no documentation that these plans were reviewed with the residents or that copies were provided. Staff interviews revealed confusion about the process and timing for care plan development and review, and residents reported not receiving or reviewing their plans of care.
A resident receiving an antidepressant was not comprehensively assessed for medication use, as required by facility policy. Documentation failed to include specific symptoms of depression, indicators for use, or non-pharmacological interventions. Staff interviews confirmed that comprehensive assessments were not completed, and care plans only addressed monitoring for side effects rather than the clinical rationale for the medication.
A resident admitted with depression and prescribed daily Prozac did not receive a comprehensive assessment of depression or mood symptoms during admission and significant change in status MDS assessments. Key assessment questions were omitted, and the Care Area Assessments failed to document specific symptoms or non-pharmacological interventions. Medication reviews and care planning did not address or monitor the resident's indications for antidepressant use.
Surveyors found that two residents were not properly screened for serious mental disorders or intellectual disabilities as required by PASARR regulations. One resident did not have a follow-up PASARR Level 1 submitted after a 30-day hospital exemption expired, and another resident's PASARR Level 1 failed to document diagnoses of anxiety disorder and unspecified psychosis, which would have triggered a Level 2 evaluation.
A resident with legal blindness and optic atrophy did not receive timely optometry services after a missed appointment was not rescheduled, despite an active request and care plan interventions. The facility lacked a system to track missed or canceled vision visits, resulting in a lapse in care and staff being unaware of the resident's ongoing vision concerns.
A resident with a history of dysphagia, hemiplegia, and other medical conditions was not provided with the required 1:1 supervision during meals, as ordered by the physician. Despite facility policy and documentation indicating the need for close monitoring, staff were observed leaving the resident unsupervised during several meals, and key team members were unaware of the supervision requirements. This lack of adherence to orders and communication among staff resulted in a deficiency related to accident prevention and resident safety.
A resident scheduled for dialysis received incorrect medication administration from an LPN, including an initially incorrect insulin dose, only one capsule each of Vitamin D and Docusate instead of two, and omission of Pantoprazole and Thiamine. The LPN acknowledged the errors, which resulted in a medication error rate of 16.67 percent, exceeding the acceptable threshold.
Staff did not follow infection control protocols for a resident on Enhanced Barrier Precautions, as both an LPN and a CNA performed high-contact care activities, including tube feeding and catheter care, without wearing gowns as required by facility policy. The resident had multiple medical conditions necessitating these precautions, and the lapses were observed despite clear signage and documented care plans.
Surveyors found that the facility did not create complete care plans for several residents on antidepressant medications, omitting individualized goals, symptoms, and non-pharmacological interventions for depression. Additionally, a resident with documented bladder incontinence did not have a care plan addressing this need. Staff interviews confirmed these omissions, and there was no evidence that adverse medication effects were reported to a physician as required.
A resident with atrial fibrillation was admitted with hospital orders for Apixaban 5 mg twice daily, but due to a transcription error by the ADON, the medication was entered as once daily in the MAR. The facility physician signed the incorrect order without documentation of awareness of the original dosage, and there was no evidence that the POA was notified of the change. The resident received half the prescribed dose for over a month, with no documented secondary review or reconciliation against the hospital discharge summary.
A resident admitted with multiple pressure injuries did not receive a comprehensive skin assessment with measurements and detailed documentation upon admission, as required by facility policy. Wound care treatments were not consistently documented as completed in the TAR for several days, and a full assessment was delayed by three days. Handwritten wound logs provided after surveyor inquiry were not part of the formal medical record and lacked essential details, resulting in incomplete and delayed documentation of the resident's condition.
Several residents reported being served undercooked chicken, with red juices contaminating other foods on their plates. Despite complaints from cognitively intact residents, there was no formal investigation to determine the cause or extent of the issue. The Dietary Manager was not present on the day of the incident, and the Nursing Home Administrator concluded only one resident had a concern after informal discussions, without processing the incident through the grievance system.
The facility failed to properly address grievances from two residents. One resident reported being served undercooked chicken, but no grievance form was initiated, and no follow-up occurred. Another resident's family member raised concerns about laundry handling and meal services, but did not receive written responses, contrary to facility policy. The facility's grievance process was not followed, leading to unresolved issues and dissatisfaction.
The facility failed to serve food at the appropriate temperature, affecting two residents who reported their meals were not hot enough. The Dietary Manager confirmed the BBQ rib patty was lukewarm and used an infrared thermometer, which read 125 degrees, below the required 135 degrees. A malfunction in the steam table was later discovered, contributing to the issue.
A resident with a history of stroke and chronic pain was left without Oxycodone for several days due to a failure in communication and documentation between the LTC facility, pharmacy, and physician. The resident relied on less effective APAP for pain relief, as the facility did not ensure a timely renewal of the prescription. The deficiency was marked by assumptions and lack of follow-up, leading to inadequate pain management.
Two residents reported receiving cold food and beverages, which were not palatable when reheated. The facility's grievance log documented ongoing concerns, and observations revealed inadequate food coverage and temperatures below acceptable levels. The Dietary Manager acknowledged potential issues with food cart usage, and the DON confirmed the temperatures did not meet facility standards.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was properly assessed by the interdisciplinary team to determine if it was clinically appropriate for the resident to self-administer medication. The facility's policy requires that residents may only self-administer medications after an interdisciplinary team assessment and documentation of the resident's preference. However, a surveyor observed a medication cup labeled with the resident's name and containing two white tablets (Tylenol) left on the overbed table. The resident, who has diagnoses including hypertension, lumbar radiculopathy, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and anxiety disorder, was found to be cognitively intact with a BIMS score of 15. The resident stated that he sometimes takes the medication himself, indicating that self-administration was occurring without the required assessment. Further review of the resident's medical record and medication administration record revealed no documentation of a self-administration assessment. Staff, including an LPN and the DON, were unable to locate such an assessment, and the LPN later acknowledged that the resident was not authorized to self-administer medication. The facility's own policy and assessment forms indicated that the resident had not expressed a desire to self-administer medications, yet the medication was left at the bedside for self-administration without proper authorization or assessment.
Failure to Provide Scheduled Showers and Adequate Bathing Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide showers as required for three residents who were dependent on staff for activities of daily living (ADLs), specifically bathing. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including scheduled showers or alternative bathing methods. However, documentation and staff interviews revealed that these residents did not consistently receive showers as scheduled, and in some cases, only bed baths were provided without documented alternatives or clear communication in care plans. One resident with hemiplegia, hemiparesis, seizures, and dementia was completely dependent on staff for all care, including bathing. Despite care plans and physician orders specifying scheduled showers, the resident only received bed baths due to poor trunk control and lack of appropriate equipment, such as a shower cot. The facility did not provide alternative bathing methods or update care documentation to reflect the resident's actual bathing routine. Bathing records showed multiple missed scheduled bathings, with the resident sometimes going up to ten days without a bath. Another resident, cognitively intact but requiring maximum assistance for bathing, was scheduled for showers twice weekly. However, review of records and staff interviews indicated that showers were often not provided as scheduled, particularly on certain days when staff expressed reluctance or cited the absence of therapy staff. The third resident, with multiple chronic conditions and mobility impairments, was also scheduled for showers twice weekly but reportedly never received a shower since admission due to lack of appropriately sized equipment. Staff documented showers in records despite only providing bed baths, and the resident reported never having their hair washed by staff. Facility leadership and staff confirmed the lack of appropriate equipment and the absence of consistent documentation or alternative bathing arrangements.
Failure to Assess and Document Change in Condition Leading to Hospitalization
Penalty
Summary
A resident with multiple chronic conditions, including hypertension, chronic Foley catheter use, and a history of urinary retention, did not receive assessment, treatment, and care in accordance with professional standards of practice following a change in condition. The resident experienced increased pain, rated at 8 out of 10, and received PRN Oxycodone during the night shift for the first time at this pain level. Despite physician orders requiring daily vital signs due to hypertension and specific documentation of pain characteristics with each PRN pain medication administration, there was no documented assessment of the cause of pain, vital signs, or pain characteristics at the time of administration. The medication administration record was blank for the required pain flow sheet documentation, and vital signs were not recorded as ordered, with the last documented set occurring nearly two weeks prior to the incident. Certified Nursing Assistants (CNAs) and nursing staff observed and reported that the resident was not feeling well, appeared unwell, and had no urine output in the urinary collection bag on the morning of the incident. The resident reported symptoms such as a hard abdomen and foul-smelling urine to both CNAs and nursing staff, but these concerns were not adequately assessed or documented. Interviews revealed that staff either did not recall or did not perform a full assessment, and there was no evidence of a comprehensive evaluation or documentation of the resident's change in condition prior to the resident being sent to a scheduled medical appointment. The facility's policy required baseline assessments and documentation for acute changes in condition, which were not followed. Upon arrival at the physician's office, the resident was found to have an empty urinary collection bag and was subsequently transferred to the emergency department, where he was diagnosed with sepsis, acute renal failure, and septic shock due to urinary obstruction from a clogged Foley catheter. Hospital records confirmed that the resident had experienced lower abdominal pain and lack of urine output for at least two days prior to admission. The lack of timely assessment, documentation, and intervention by facility staff in response to the resident's change in condition and physician orders led to a significant health decline requiring ICU admission.
Failure to Follow Infection Control Protocols During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene, improper use of personal protective equipment (PPE), and inappropriate handling of a urinary collection bag for a resident on enhanced barrier precautions. During incontinence care, a Licensed Practical Nurse (LPN) was observed wearing only gloves, without a gown, while providing care to a resident with an indwelling urinary catheter and enhanced barrier precautions in place. The LPN also handled the resident’s urinary collection bag, which was found lying directly on the floor and partially under the bed’s stabilizing section, contrary to facility policy and CDC guidelines. The LPN did not perform hand hygiene before leaving the resident’s room after completing care tasks. Further observations revealed that a Certified Nursing Assistant (CNA) failed to remove gloves and perform hand hygiene after blowing her nose and after providing perineal care involving exposure to fecal matter. The CNA continued to perform additional care tasks, such as applying cream and repositioning the resident, without changing gloves or washing hands. Both the LPN and CNA did not consistently follow the facility’s policies regarding hand hygiene and the use of gowns and gloves during high-contact care activities for residents on enhanced barrier precautions. The resident involved had multiple medical conditions, including hypertension, lumbar radiculopathy, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and anxiety disorder. The resident required substantial assistance with toileting and hygiene and had an indwelling urinary catheter, necessitating enhanced barrier precautions. Despite clear facility policies and physician orders for the use of gowns and gloves during high-contact care, staff did not adhere to these protocols, resulting in a failure to reduce the risk of disease and infection transmission.
Failure to Honor Resident Dignity and Clothing Preferences
Penalty
Summary
Surveyors found that the facility failed to ensure residents were treated with dignity and respect, specifically regarding their preference to be dressed in regular clothing rather than gowns. Multiple residents were observed over several days in gowns, both in their rooms and in common areas such as hallways and the dining room. Interviews with these residents revealed that they preferred to be dressed in clothes, with some expressing discomfort and stating they were cold in gowns. Residents also reported that they had communicated their preferences to staff, but their requests were not consistently honored. The facility's own policy requires staff to make reasonable accommodations for residents' needs and preferences, including assistance with dressing. Despite this, staff interviews indicated that if residents did not have clothes available, they were simply dressed in gowns. Staff acknowledged the existence of donated clothing in the facility's laundry, but there was a lack of consistent communication and follow-through to ensure residents had access to appropriate clothing. Some staff stated they would only provide clothes if informed by other departments, and there was no systematic process to ensure residents' closets were stocked with clothing. The affected residents had varying levels of cognitive and physical impairment, with some requiring substantial assistance for dressing and expressing that choosing their own clothes was important to them. Observations showed that residents' personal grooming and hygiene were also neglected, as evidenced by disheveled hair and unshaven faces. The deficiency persisted until family members intervened or until the last day of the survey, when residents were finally observed dressed in regular clothing.
Failure to Timely Inform Residents of Rights, Services, and Financial Information Upon Admission
Penalty
Summary
The facility failed to ensure that four residents were fully informed of their rights, rules, services, charges, and required financial information prior to or upon admission. Specifically, these residents did not receive or sign the admission agreement, which includes consent for treatment, financial agreements, and resident rights and responsibilities, within a reasonable timeframe. In several cases, the admission agreement was not acknowledged until days or weeks after admission, and in some instances, not at all before discharge. For example, one resident was admitted and discharged without ever signing the admission agreement or being informed of the facility's policies regarding safeguarding personal belongings. This resident later reported missing a significant amount of money, and there was no documentation that the facility had reviewed options or restrictions for safeguarding possessions with the resident. Other residents experienced similar delays, with admission agreements not reviewed or signed until well after admission, and in some cases, only after a second admission to the facility. Interviews with admissions staff revealed that there was no specific timeline for reviewing the admission agreement with residents, and it was common for the process to be delayed by several days. The facility's own policies require that residents be provided with information about services, rights, and financial matters prior to or upon admission, but these procedures were not consistently followed. As a result, residents were not fully informed of their rights, financial options, or consent for treatment in a timely manner.
Failure to Timely Develop and Review Baseline Care Plans with Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for multiple residents, as required by policy. Several residents, including those with complex medical conditions such as congestive heart failure, diabetes, and end-stage renal disease, were admitted or readmitted to the facility, but their baseline care plans were either not completed within the required timeframe or lacked documentation that the plans were reviewed with the residents or their representatives. In some cases, baseline care plans were signed by staff several days after admission, and there was no evidence that residents received a copy of their care plan or participated in its review. Interviews with residents revealed that they did not recall receiving a plan of care or any related documentation, and some stated they had never received such information during multiple admissions. Record reviews confirmed the absence of documentation showing that baseline care plans were provided to or reviewed with the residents. Additionally, care plan meetings were held, but there was no documentation that the plans of care were discussed with the residents during these meetings. Staff interviews indicated a lack of clarity regarding the process and timing for completing and reviewing baseline care plans. Nursing managers and social workers acknowledged that baseline care plans were typically reviewed with residents at the first care conference, which often occurred after the 48-hour window. Documentation of resident receipt and review of the care plan was inconsistent or missing, and staff admitted that signatures from residents or their representatives were not routinely obtained or documented.
Lack of Comprehensive Assessment for Antidepressant Use
Penalty
Summary
A deficiency was identified when a resident admitted with diagnoses of depression and stroke was prescribed an antidepressant medication (Prozac) without a comprehensive assessment for its use. The facility's policy requires documentation of clinical rationale, including assessment of the resident's condition, therapeutic goals, and consideration of non-pharmacological interventions before administering psychotropic medications. However, the resident's medical record, care plans, and medication review forms lacked documentation of specific symptoms of depression, indicators for use, and non-pharmacological interventions. The Care Area Assessments (CAAs) completed by the MDS RN only noted the medication was for depression but did not detail the resident's symptoms or alternative interventions attempted. Interviews with facility staff, including the Unit Manager and Social Worker, confirmed that comprehensive assessments for psychotropic medication use were not completed, and they did not document symptoms or non-pharmacological approaches. Medication reviews and care plans focused on monitoring side effects but did not provide evidence supporting the need for the antidepressant or describe behavioral symptoms and their frequency. Even after the resident declined formal psychological services, there was no plan of care established to monitor or address the indications for antidepressant use.
Failure to Complete Comprehensive Depression Assessment and Care Planning for Antidepressant Use
Penalty
Summary
The facility failed to conduct a comprehensive assessment of depression and mood for a resident who was admitted with diagnoses of depression and stroke and prescribed daily Prozac. Upon admission and during a significant change in status, the Minimum Data Set (MDS) assessments did not fully evaluate the resident's depression or mood symptoms, omitting key questions and resulting in incomplete severity scoring. The Care Area Assessments (CAA) for psychotropic drug use documented the use of Prozac but did not include the resident's specific symptoms or any non-pharmacological interventions. Interviews with the MDS Registered Nurse and Social Worker revealed that they only coded the medication and did not assess or document the symptoms or comprehensive needs related to the antidepressant use. Further review of medication records and care conference notes showed that medication reviews lacked documentation of behaviors, their frequency, and non-pharmacological interventions for depression. The care plan did not address or monitor the indications for antidepressant use or interventions, despite the resident declining formal psychological services. A late entry PHQ-9 assessment was submitted, but there was no evidence it contributed to accurate MDS assessments or care planning for the resident's antidepressant therapy.
Failure to Complete Accurate and Timely PASARR Screenings
Penalty
Summary
The facility failed to ensure accurate and timely PASARR (Preadmission Screening and Resident Review) screenings for residents with potential mental disorders or intellectual disabilities. For one resident, a PASARR Level 1 screen was completed prior to admission and a 30-day hospital exemption was documented, which allowed admission without a Level 2 screen. However, after the resident remained in the facility beyond the 30-day exemption period, the facility did not resubmit a PASARR Level 1 as required. The Nursing Home Administrator confirmed that a follow-up PASARR was not completed prior to the expiration of the exemption, despite the resident having diagnoses of dementia and unspecified psychosis and being prescribed antipsychotic and antianxiety medications. For another resident, the facility failed to accurately document the presence of a serious mental illness on the PASARR Level 1 screen. The resident was admitted with diagnoses including anxiety disorder and unspecified psychosis, both of which are considered major mental disorders under DSM-5 criteria. Despite this, the PASARR Level 1 indicated that the resident did not have a major mental disorder, which prevented the initiation of a Level 2 PASARR evaluation. The Nursing Home Administrator stated that the answer was marked "NO" because there was no diagnosis to substantiate a "YES," even though the resident's medical record included relevant diagnoses. These deficiencies were identified through interview and record review by surveyors, who noted that the facility's practices did not align with its own policy and state requirements for PASARR screening. The lack of accurate and timely PASARR assessments resulted in residents not being properly evaluated for serious mental illness or intellectual disability as required.
Failure to Ensure Timely Vision Services for Resident with Legal Blindness
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of legal blindness and optic atrophy did not receive timely and appropriate vision care services. The resident had not been seen by an optometrist since a missed appointment, and the missed visit was never rescheduled despite an active request and signed consent for vision care. The resident's care plan included interventions such as arranging consultations with an eye care practitioner and monitoring for acute eye problems, but these interventions were not effectively implemented. Record review and interviews revealed that the process for scheduling vision appointments relied on the resident's request and consent, after which the resident would be placed on a list for quarterly visits by an external provider. However, after the resident missed a scheduled visit due to being in bed, there was no follow-up to ensure the resident remained on the provider's list or to reschedule the appointment. The facility lacked a tracking mechanism to monitor whether visits occurred, were missed, or canceled, and there was no system to identify if a resident was no longer receiving services. The resident reported ongoing vision issues and expressed a desire for a vision appointment, but staff were unaware of the lapse in care and did not inform the resident of any upcoming appointments. Interviews with staff indicated uncertainty about responsibility for tracking missed or discontinued services, and there was no documentation or system in place to ensure continuity of vision care for the resident.
Failure to Provide Required 1:1 Supervision During Meals for Resident with Swallowing Difficulties
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure safety to prevent accidents for a resident with significant swallowing difficulties and other complex medical conditions. The resident had physician orders for 1:1 supervision during all meals due to a history of dysphagia, hemiplegia, and other health issues that increased the risk of choking and aspiration. Despite these orders, multiple surveyor observations documented that the resident was left unsupervised during several meals, with staff either delivering trays and leaving or only providing setup assistance without remaining present for supervision. The facility's own policies required identification of hazards, implementation of interventions, and monitoring for effectiveness, including providing supervision as an intervention to mitigate accident risk. However, the resident's care card and comprehensive care plan were not updated to reflect the physician's order for 1:1 supervision, and there was confusion among staff, including the speech-language pathologist and dietitian, regarding the resident's required level of supervision. Interviews revealed that key staff members were unaware of the current physician orders, and documentation in the Treatment Administration Record indicated staff were signing off on supervision that was not actually being provided. Surveyor interviews and observations further highlighted a lack of communication and coordination among the interdisciplinary team regarding the resident's dietary and safety needs. The speech-language pathologist was not aware of the 1:1 supervision order, and the dietitian could not recall reviewing the relevant hospital paperwork or physician orders. The resident was observed eating without supervision on multiple occasions, contrary to the documented orders and facility policy, leading to the identified deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as required by policy, resulting in a medication error rate of 16.67 percent during the observed medication pass. During the observation, an LPN was seen preparing and administering medications to a resident who had a blood sugar of 216 and was scheduled to go to dialysis. The LPN initially drew up the incorrect dose of 70/30 insulin (5 units instead of the ordered 3 units) but corrected the dose before administration after the error was noticed. Additionally, the LPN administered only one capsule each of Vitamin D and Docusate, despite orders for two capsules of each, and omitted administration of Pantoprazole Sodium and Thiamine, both of which were ordered for the resident at that time. Upon interview, the LPN acknowledged the errors, attributing them to being flustered by the resident's presence at the medication cart and the urgency of the resident needing to leave for dialysis. The LPN confirmed that only one capsule each of Vitamin D and Docusate was given, and that Pantoprazole and Thiamine were not administered as ordered. The surveyor confirmed these omissions and incorrect dosages through observation and review of the medication administration records and physician orders.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols for a resident who required Enhanced Barrier Precautions (EBP) due to multiple medical conditions, including a cerebral aneurysm, hemiplegia, dysarthria, and a dysfunctional bladder. The resident's care plan and facility policy required staff to wear gowns and gloves during high-contact care activities, such as tube feeding and catheter care, to prevent the transmission of multidrug-resistant organisms (MDROs). Despite clear signage and documented requirements, staff were observed performing these high-contact activities without donning gowns. Specifically, a nurse was seen changing the resident's tube feeding without a gown, and a CNA handled the resident's catheter bag and privacy cover without appropriate PPE. The Assistant Director of Nursing was present during one of these incidents and acknowledged the lapse, subsequently educating the staff involved. The deficiency was identified through direct observation, interviews, and review of the resident's records, which confirmed that the required infection control measures were not consistently implemented during resident care.
Failure to Develop Comprehensive Care Plans for Depression and Bladder Incontinence
Penalty
Summary
Surveyors identified that the facility failed to develop comprehensive care plans for residents prescribed antidepressant medications and for a resident with bladder incontinence. For two residents admitted on antidepressant medications, the care plans did not address the underlying depression diagnosis, lacked documentation of specific symptoms, and omitted non-pharmacological interventions. The care plans focused only on monitoring medication side effects, without including individualized goals or interventions for depression itself. Interviews with facility staff confirmed that care plans were not comprehensive and that staff did not routinely assess or document symptoms related to depression. Additionally, for one resident with a diagnosis of depression and documented occasional bladder incontinence, the care plan did not include any interventions or goals related to bladder care, despite this being noted in the resident's Minimum Data Set (MDS) assessment. Staff responsible for reviewing and updating care plans were unable to provide explanations for the omissions or recall relevant details about the resident's care needs. The lack of a bladder care plan was confirmed during interviews and review of the resident's records. The survey also found that, for one resident, adverse effects from depression medication were documented on several dates, but there was no evidence that these effects were reported to a physician as required by the care plan. The facility did not provide additional information or documentation to explain why the care plan interventions were not followed or why comprehensive care plans were not developed for the residents in question.
Medication Transcription Error Resulted in Incorrect Anticoagulant Dosing
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with hospital discharge orders for Apixaban 5 mg to be administered twice daily, once in the morning and once at bedtime, for atrial fibrillation. The Assistant Director of Nursing (ADON) transcribed the order incorrectly into the facility's Medication Administration Record (MAR) as Apixaban 5 mg once daily, resulting in the resident receiving only half the prescribed dose for 34 days. The facility physician signed off on the transcribed order without documentation indicating awareness of the original hospital order or an intentional change in dosage. There was also no documentation that the resident's Power of Attorney (POA) was notified of the change in medication dosage. Interviews with facility staff revealed that the process for entering and double-checking new admission orders lacked documentation of a secondary review. The Unit Manager Registered Nurse (UMRN) confirmed that while orders were supposed to be double-checked by another administrative nurse, there was no place in the electronic medical record to document this verification. The ADON acknowledged the error in transcription and stated that the order should have been entered as twice daily, as per the hospital discharge summary. Further review of physician progress notes and interviews indicated that the physician reviewed and reconciled the medication list as it appeared in the facility's MAR, which already contained the transcription error. There was no evidence that the physician compared the facility's orders to the hospital discharge summary or that any intentional change to the Apixaban dosage was made. As a result, the resident received an incorrect dose of a critical anticoagulant medication throughout their stay.
Incomplete and Delayed Wound Documentation for Resident with Multiple Pressure Injuries
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurately documented, and readily accessible, as required by facility policy and professional standards. Upon admission, the resident, who had a history of encephalopathy, diabetes, dementia, and rheumatoid arthritis, presented with multiple pressure injuries, including a Stage 4 pressure injury, several unstageable wounds, and deep tissue injuries. Although the facility's policy required a comprehensive skin assessment with measurements and detailed documentation upon admission, the initial assessment lacked critical information such as wound measurements, staging, etiology, and detailed descriptions. Additionally, the documentation did not specify the number or precise locations of wounds on the toes and feet. Treatment orders for the resident's wounds were not consistently documented as completed in the Treatment Administration Record (TAR) for several days following admission. Specifically, wound care orders for the right lower extremity, coccyx, right hip, and left foot and toes were not signed out as completed on multiple dates. The comprehensive assessment of the resident's pressure injuries was not performed until three days after admission, contrary to facility policy and expectations for timely assessment and documentation. The lack of timely and complete documentation hindered the ability to track wound progression and ensure appropriate care. When concerns were raised by the surveyor, the facility provided handwritten wound logs and assessment forms that were not part of the formal medical record and lacked essential information such as the identity of the person documenting and specific dates. These documents were only submitted after the surveyor's inquiry and were not originally included in the resident's official medical record. The incomplete and delayed documentation, as well as the absence of required information in the medical record, constituted a failure to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards.
Undercooked Chicken Served to Residents
Penalty
Summary
The facility failed to ensure that foods were prepared in a way that prevented the risk of foodborne illness for five of ten sampled residents. On 11/16/24, several residents reported being served undercooked chicken, with red juices contaminating other foods on their plates. Residents R2, R5, R7, R8, and R10, all cognitively intact, expressed concerns about the undercooked chicken and the lack of alternative meal options, which left them hungry. Despite these complaints, there was no formal investigation to determine the cause of the undercooked chicken, the number of residents affected, or the necessary steps to prevent potential foodborne illness. The Dietary Manager (DM) was not present on the day the undercooked chicken was served and only learned of the issue afterward. The DM checked the leftover chicken and found some pieces slightly pink but not bloody, and the cook denied any undercooking. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the issue, but the NHA concluded that only one resident had a concern after informal discussions with a few residents. The incident was not processed through the grievance system, and no interviews were conducted with the CNAs who served the meal, indicating a lack of thorough investigation and response to the residents' complaints.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to properly identify and address grievances from residents, as evidenced by the experiences of two residents, R2 and R3. R2, who was cognitively intact, reported an incident where she and other residents were served undercooked chicken, which was inedible, leaving her hungry. Despite reporting this as a formal complaint to the Dietary Manager (DM), no grievance form was initiated, and no follow-up was conducted. The DM acknowledged the complaint but did not take further action to investigate or document it as a grievance. The Social Services Grievance Official was unaware of the incident, and the Nursing Home Administrator (NHA) handled the issue informally without following the grievance process. R3's family member expressed multiple concerns regarding the handling of R3's laundry and meal services, including missing and damaged clothing, and a meal tray left in R3's room with gnats. Although these grievances were documented, the family member did not receive written responses or resolutions, and was often dissatisfied with the verbal outcomes provided. The facility's policy required written decisions on grievances, but this was not adhered to, as confirmed by the Social Services staff and the NHA, who stated that results were typically communicated verbally. The facility's failure to follow its grievance policy resulted in a lack of formal documentation and resolution of resident complaints. The designated Grievance Official was not informed of all grievances, and the process for issuing written decisions was not followed, leading to unresolved issues and dissatisfaction among residents and their families. This deficiency highlights a breakdown in the facility's grievance handling process, impacting the residents' right to voice concerns and receive appropriate responses.
Failure to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to serve food at the appropriate temperature, affecting two residents who reported that their meals were not hot enough. Both residents were cognitively intact, as indicated by their BIMS scores of 15 out of 15. During an observation, one resident stated that the BBQ rib patty was not very hot, while another resident confirmed the same but noted that the taste was acceptable. The Dietary Manager (DM) confirmed that the BBQ rib patty was lukewarm and that the plate was cold, which contributed to the food not being served at the proper temperature. The DM used an infrared thermometer to check the temperature of the BBQ rib patty, which read 125 degrees, below the required serving temperature of 135 degrees. The steam table holding temperature was recorded at 186 degrees, indicating a discrepancy between the holding and serving temperatures. The Maintenance Director (MD) later discovered a malfunction in the steam table, with one well reading 120 degrees due to a broken switch on the circuit board. This issue was not known to the facility until the deficiency was identified.
Failure to Monitor Narcotic Medication Delivery
Penalty
Summary
The facility failed to monitor the delivery of narcotic medication for a resident, leading to a deficiency in pain management. The resident, who was cognitively intact and had a history of stroke, breast cancer, osteoarthritis, anxiety, and asthma, was admitted with orders for Oxycodone and Acetaminophen (APAP) for pain management. The resident reported that she usually took Oxycodone once a day and did not need APAP. However, from 03/04/24 to 03/08/24, the facility did not have Oxycodone available for the resident, and she had to rely on APAP, which was not as effective for her pain relief. The issue arose because the facility did not ensure a new prescription for Oxycodone was obtained in a timely manner. The Licensed Practical Nurse (LPN) and the Director of Nurses (DON) both assumed that the pharmacy would contact the physician for a new prescription, as was sometimes the practice. However, there was no documentation of such communication, and the pharmacy did not receive a prescription from the physician until 03/08/24. The resident experienced pain during this period, and although the facility provided APAP and non-pharmacological interventions, the resident reported that the pain relief was not as effective as with Oxycodone. The deficiency was further compounded by a lack of documentation and communication between the facility, the pharmacy, and the physician. The DON and LPN believed that the pharmacy would handle the prescription renewal, but there was no follow-up to ensure the prescription was sent and filled. The physician also assumed the prescription was filled after sending it on 03/05/24, but the pharmacy did not receive it until 03/08/24. This lack of coordination and documentation led to the resident being without her prescribed Oxycodone for several days, affecting her pain management.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for two residents on one of its units. Resident 1, who was alert and oriented, reported that her food was often cold and beverages were not cold enough. She had previously complained about the issue and was advised to ask staff to reheat her food, which she found unpalatable when reheated. Similarly, Resident 4 also reported that her food was sometimes cold and did not taste good when reheated. The Dietary Manager stated that since the purchase of two food carts with heating elements, there had been only a few complaints about cold food. However, the facility's grievance log documented Resident 1's ongoing concerns about cold food. The review of the facility's food temperature logs revealed a lack of documentation for milk and coffee temperatures before leaving the kitchen. During an observation, it was noted that food items were not adequately covered, and the temperatures of the test tray items were below acceptable levels, with the cheeseburger, French fries, pineapples, and milk being lukewarm and not palatable. The facility's policy required hot foods to be held at 135 degrees Fahrenheit or greater and cold foods at or below 41 degrees Fahrenheit. However, the test tray temperatures were significantly lower than these standards. The Dietary Manager acknowledged that the food cart might not have been plugged in early enough, contributing to the cooler food temperatures. The Director of Nurses confirmed that the temperatures were not at acceptable levels, indicating a failure to adhere to the facility's food temperature policies.
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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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