Complete Care At Hales Corners
Inspection history, citations, penalties and survey trends for this long-term care facility in Hales Corners, Wisconsin.
- Location
- 9449 W. Forest Home Ave., Hales Corners, Wisconsin 53130
- CMS Provider Number
- 525596
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Complete Care At Hales Corners during CMS and state inspections, most recent first.
A resident with dementia and age-related osteoporosis, who had severe cognitive impairment, was observed receiving personal care from a CNA while undressed, with the room door and privacy curtains left open, making the resident visible from the hallway. The CNA later admitted not providing privacy and dignity, and both the RN supervisor and DON stated that staff are expected to ensure privacy and appropriate coverage during care. Facility admission documents state that residents are to be afforded dignity, respect, and privacy in treatment and care for personal needs.
The facility failed to conduct and document comprehensive investigations into allegations of neglect and abuse. In one case, a cognitively intact resident with cardiac and wound issues had a family member allege neglect after the resident was found with significant leg and foot swelling and was sent to the ED for acute CHF exacerbation; the facility’s investigation did not include interviews with other residents or staff education, despite policy requirements. In another case, a resident with vaginal cancer reported feeling intimidated when a CNA made a threatening remark after an accusation, yet the facility’s investigation did not include abuse-related education or further corrective action, and did not fully consider the CNA’s documented history of prior resident complaints about disrespectful communication, failure to follow resident preferences, and inadequate care setup.
A resident's legal representative, who held POA, requested copies of the resident's medical records but did not receive them due to staff oversight. The request form was completed and signed, but the Medical Records staff, relying on incorrect information, failed to process the request, resulting in the records not being provided as required by facility policy.
A resident with advanced dementia and a chronic facial mass developed a maggot infestation that was not consistently monitored or addressed in the care plan. Staff failed to investigate the cause of the infestation, did not document consistent interventions, and lacked a comprehensive plan to manage the maggots or the resident's refusals of care, resulting in a deficiency in providing care according to professional standards.
A resident with a left facial mass and multiple comorbidities was found with maggots and flies present on the wound, with nursing staff documenting ongoing issues of flies and maggots over several weeks. Despite the facility's pest control policy and regular general pest treatments in common areas, there was no evidence that pest control services were increased or that the resident's room was specifically treated for flies, and staff confirmed that exterminators were not directed to address flies in resident rooms.
Three residents with significant medical needs were transferred to the hospital on multiple occasions without receiving the required transfer and bed hold notices, including information on appeal rights and ombudsman contact details. This lapse occurred after the facility switched to a new EMR system, which did not automatically generate the necessary documentation, and staff did not provide the notices as required.
A resident with a history of dementia and prior ORIF surgery developed a wound that was not promptly or thoroughly assessed by clinical staff. The facility failed to document the wound's type and location, did not consult an orthopedic specialist when hardware was observed protruding, and lacked a care plan for pressure injury prevention prior to the wound's discovery. Physician assessments were incomplete, and oversight of the wound care program was unclear, resulting in delayed and insufficient evaluation and documentation.
Two residents did not receive necessary nutrition services: one experienced significant unaddressed weight loss without timely physician or dietician notification or care plan updates, and another, requiring supervision during meals due to severe cognitive impairment, was repeatedly left unsupervised while eating.
Staff did not follow established recipes when preparing pureed food, instead blending untoasted white bread with liquid cheese powder mix and relying on visual judgment for consistency. The food prepared for residents on pureed diets did not match the regular diet food, and available recipes were not used despite being accessible.
A resident with cognitive and physical impairments did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets, such as built-up utensils, a divided plate, and a nosey cup. Multiple observations showed that the required devices were often missing from the resident's meal trays, despite being documented as necessary and listed on tray tickets. Staff interviews confirmed inconsistencies in the process and a limited supply of certain adaptive items.
A resident with severe cognitive impairment reported being pushed by a CNA. The CNA was suspended and an investigation was conducted, including interviews and a body check that found no injuries. Despite facility policy requiring notification, law enforcement was not contacted regarding the abuse allegation.
The facility failed to provide appropriate pressure ulcer care and accurate documentation for two residents, leading to the deterioration of their wounds. The care plans were not updated, and the physician was not notified of changes in the wounds' presentation.
A resident reported a missing wallet containing money, credit cards, insurance cards, and a driver's license. The Social Worker interviewed the resident's family and staff but did not interview other residents to determine if they had any knowledge of the missing wallet or if they had any personal items missing. The Nursing Home Administrator was informed of the concern, but no further information was provided.
Failure to Provide Privacy and Dignity During Personal Care
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and privacy when a CNA provided personal care to one resident without closing the room door or drawing the privacy curtains. The resident, identified as R3, had been admitted with diagnoses including dementia and age-related osteoporosis, and had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. On 02/19/26 at 5:30 AM, observation from the hallway showed CNA1 at the resident’s bedside performing care while the resident was undressed, with the curtains and door open, making the resident visible from the hallway. During a subsequent interview at 5:37 AM, CNA1 acknowledged that she failed to provide privacy and dignity for the resident by not drawing the curtains and closing the door during care. At 5:40 AM, the nursing supervisor (RN3) stated that her expectation was that CNA1 should have provided privacy and dignity regardless of the time of day. Later, at 6:00 PM, the DON stated it was her expectation that CNA1 should have covered the resident during care. Review of the facility’s undated Admission Agreement showed that the facility committed to ensuring residents’ rights to dignified existence, respect, individuality, consideration, and privacy in treatment and care for personal needs, and to protecting and promoting each resident’s rights.
Failure to Conduct and Document Comprehensive Abuse/Neglect Investigations
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough investigation into an allegation of neglect for one resident and to fully evaluate a CNA’s history of concerning interactions with residents during an abuse/neglect investigation. One resident was admitted with diagnoses including myocardial infarction, congestive heart failure, and cellulitis. After a family member reported concern about swelling in the resident’s feet, nursing staff assessed the resident, noted bilateral leg and foot swelling, and recommended emergency room evaluation, after which the resident was admitted to the hospital for acute exacerbation of chronic heart failure. The family member later alleged neglect, and a grievance was filed with the assistance of the social worker. Despite this allegation and the resident’s documented cognitive intactness (BIMS score of 13/15), the facility’s investigation records did not show that other residents were interviewed about neglect concerns or that staff were educated on abuse and neglect policies as part of a comprehensive investigation. The Administrator stated she did not consider it necessary to interview other residents because she viewed the case as unique and without similar concerns among other residents, and she did not consider staff training necessary because she believed there was no actual neglect or abuse in this case. This approach was inconsistent with the facility’s written Abuse, Neglect and Exploitation policy, which requires immediate investigation procedures including identifying and interviewing all involved persons and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation. A separate incident involved another resident with vaginal cancer who alleged that a CNA entered her room, came close to her, and stated, “Be sure you know who you accuse,” which the resident reported as intimidating. The facility’s investigation concluded the allegation was unsubstantiated and did not include documentation of abuse-related education or other training for the CNA or staff. Review of the CNA’s personnel file showed multiple prior resident complaints, including telling a resident to be more independent and not ensuring needs were met after providing supplies, using an authoritative tone, yelling at another resident for being wet, making embarrassing comments about incontinence, insisting on clothing choices against resident preference, repeating completed care tasks, and leaving a resident on the toilet long enough to play two games on her phone. Although the CNA had been placed on performance improvement plans for customer service, respectful communication, and resident rights, the Administrator reported she was unaware of all documented concerns and believed she could not use prior personnel records after a change in facility ownership. The facility’s investigation into the later abuse allegation did not reflect a review and integration of this history as part of a comprehensive investigation, contrary to the facility’s policy requiring complete and thorough documentation and focus on determining whether abuse, neglect, or mistreatment occurred.
Failure to Provide Resident Records to Legal Representative
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's legal representative with access to or copies of the resident's medical records upon request. The resident, who had multiple complex diagnoses including fractures, heart disease, dementia, and other chronic conditions, was admitted to the facility and had a power of attorney (POA) designated as his daughter. The facility's policy required that, upon receiving a valid request for medical records, the requesting party should be notified of the cost and records should be made available after payment is received. The policy also specified that records should be gathered and secured once a request is made. Despite these procedures, the resident's daughter/POA submitted a completed and signed request form for the medical records. However, the Medical Records staff member failed to recognize that the form had been filled out and, based on incorrect information from the previous Nursing Home Administrator, believed the form was incomplete. As a result, the request was not processed, and the records were not provided to the resident's representative. This failure was confirmed during the survey when the completed form was found in an envelope, unprocessed, and the staff acknowledged the oversight.
Failure to Develop and Implement Care Plan for Maggot Infestation
Penalty
Summary
A resident with advanced dementia, chronic left facial mass (squamous cell carcinoma), and multiple comorbidities was observed to have a maggot infestation on the facial mass. The resident had a history of refusing treatment for the facial mass, which had been present and growing for at least two years. Despite the presence of a care plan for impaired skin integrity and infection risk, there was no specific care plan or consistent interventions documented for the management of maggots on the resident's facial mass. Nurses' notes and care plans did not consistently address the presence, monitoring, or treatment of maggots, and there was a lack of documentation regarding the number of maggots or the effectiveness of interventions. The facility failed to investigate the cause of the maggot infestation and did not develop or implement a comprehensive plan of care to address the infestation or the resident's refusals of care. Staff interviews revealed inconsistent awareness and documentation of the maggot issue, with some staff reporting direct observation of maggots and others denying any knowledge. The Director of Nursing and RN Supervisor were unable to provide evidence of an investigation into how the infestation occurred or how it was being managed, aside from sporadic notes and a brief incident report that lacked detailed follow-up or staff interviews. Throughout the period of infestation, there was no consistent monitoring or progress notes regarding the presence or removal of maggots, and interventions were sporadic and not clearly documented in the care plan. The lack of a specific maggot care plan, inconsistent monitoring, and absence of a thorough investigation into the infestation represent a failure to provide treatment and care in accordance with professional standards of practice and the resident's needs.
Failure to Address Fly Infestation in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in a resident with a left facial mass being found with maggot-like organisms on the mass. The resident, who had diagnoses including dementia, hypertension, depression, and squamous cell carcinoma of the skin, was observed on multiple occasions to have maggots and flies present on and around the facial wound. Nursing documentation described ongoing issues with maggots and flies, including observations of flies hovering around the resident and worms emerging from the wound. Despite these findings, there was no evidence that pest control services were increased or that the resident's room was specifically treated for flies during the period in question. Review of pest management inspection reports revealed that while general pest control treatments were conducted monthly in common facility areas, there was no documentation of targeted treatment for flies in the affected resident's room. Staff interviews confirmed the presence of flies in the room and indicated that the exterminator was not asked to address flies in resident rooms. The facility's pest control policy required a reporting system for issues arising between scheduled visits and treatment as indicated, but this was not implemented in response to the fly infestation in the resident's room.
Failure to Provide Required Transfer and Bed Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required transfer and bed hold notices to residents and/or their representatives during hospitalizations, as identified for three residents reviewed for hospitalization. Specifically, when residents were transferred to the hospital on multiple occasions, there was no documentation that the residents or their representatives received notices regarding the transfer, the reason for transfer, the location, appeal rights, or contact information for the State Long-Term Care Ombudsman. This deficiency was confirmed through interviews and record reviews, which showed that the facility had not been issuing these notices since switching to a new electronic medical record (EMR) system at the beginning of the year. The affected residents included individuals with significant medical conditions, such as a right leg fracture and chronic kidney disease, who experienced changes in condition necessitating hospitalization. Staff interviews revealed that the previous EMR system automatically generated the required notices, but the new system did not, resulting in a lapse in compliance. Despite some communication with families about bed hold options, there was no evidence that the formal transfer and bed hold notices were provided as required by facility policy and federal regulations.
Failure to Provide Timely and Comprehensive Wound Assessment and Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following the development of a wound. The resident, who had a history of dementia and an ankle fracture treated with open reduction and internal fixation (ORIF), was admitted to the facility and identified as being at risk for pressure ulcers. Despite this risk, there was no care plan in place for pressure injury prevention prior to the discovery of the wound. Upon identification of the wound, the facility did not document a comprehensive assessment to determine the wound type, nor did they specify the wound's location in initial evaluations. The facility's documentation was inconsistent and incomplete regarding the evaluation, assessment, treatment, and outcomes of the resident's wound. The wound was initially documented as an unstageable pressure injury without a clear location, and subsequent records failed to clarify whether the wound was pressure-related or associated with the resident's orthopedic hardware. There was also a lack of timely consultation with an orthopedic specialist when hardware was observed protruding from the resident's skin. Physician assessments did not include comprehensive wound evaluations or documentation of treatment progress, and the wound care plan was not updated until after the wound was discovered. Interviews with facility staff revealed that oversight of the wound care program was unclear, with responsibilities divided between the wound nurse, DON, and a newly hired nurse practitioner. The medical director acknowledged awareness of the hardware protrusion but did not provide documentation of a direct assessment. The wound nurse was unavailable for interview, and the facility was unable to provide evidence of timely or thorough physician evaluation of the wound. Ultimately, a nurse practitioner later determined the wound was related to the internal orthopedic device, not pressure, but this assessment occurred well after the initial deficiency in care and documentation.
Failure to Provide Adequate Nutrition and Supervision During Meals
Penalty
Summary
Two residents did not receive the necessary services to maintain acceptable nutrition and hydration. One resident with multiple diagnoses, including multiple sclerosis, atrial fibrillation, and dementia, experienced a 7.65% weight loss over approximately one month. This significant weight loss was not communicated to the physician or dietician, and there was no evidence of a comprehensive assessment or updated care plan to address the weight loss. The facility's policy required notification of the physician and dietician for significant weight changes, but this was not followed. Additionally, the resident was served food items not appropriate for their prescribed mechanical soft diet, and the correct dessert was not provided as indicated on the meal ticket. The dietary manager reported that weight monitoring was conducted monthly, and significant weight loss would be addressed at the next scheduled meeting. However, there was no documentation that the recent weight loss was addressed promptly or that interventions were implemented based on a comprehensive nutritional assessment. The facility's process for monitoring and responding to weight changes did not ensure timely communication or intervention for the resident's nutritional needs. Another resident with severe cognitive impairment and a care plan requiring supervision or touching assistance with eating was observed on two occasions eating unsupervised in their room. The resident's care plan and facility records indicated the need for supervision during meals, but staff did not provide the required assistance. The resident was left alone with their meal tray, and staff only entered the room briefly to assist with removing lids or to help with toileting, leaving the resident unsupervised for the majority of the meal.
Failure to Follow Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that food prepared for residents on a pureed diet was made according to established recipes designed to conserve nutritive value and flavor. During observation, Cook-C was seen preparing pureed grilled cheese by blending untoasted white bread with liquid cheese powder mix, without following a recipe. When questioned, Cook-C confirmed not using a recipe for pureed foods. The Food Service Manager (FSM)-D also stated that while recipes for pureed foods are available on the computer, they are not used, and the cook relies on visual judgment for consistency. FSM-D further clarified that the pureed food prepared did not match the regular diet food provided to other residents. The facility's policy on pureed food preparation requires that food be prepared to conserve nutritive value, flavor, and appearance, but does not specifically mandate the use of recipes. The recipe provided for pureed grilled cheese called for processing portions of grilled cheese sandwiches from the regular recipe and gradually adding hot milk, but did not specify the number of sandwiches to use. The surveyor found that the method observed did not align with the documented recipe or the food served to residents on a regular diet. No additional information was provided by facility leadership regarding the failure to follow recipes for pureed food.
Failure to Consistently Provide Required Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Parkinson's disease, osteoarthritis, osteoporosis, and unspecified lack of coordination did not consistently receive the adaptive eating equipment specified in their care plan and meal tray tickets. The resident's care plan and occupational therapy notes indicated the need for built-up silverware, a divided plate, and a small nosey cup to support independent eating and drinking. Despite these documented needs, multiple observations by the surveyor revealed that the resident's meal trays frequently lacked one or more of the required adaptive devices, such as the divided plate and nosey cup, even though these items were listed on the tray tickets. Interviews with facility staff, including dietary aides, certified nursing assistants, and the food service director, confirmed that the process for ensuring adaptive equipment was collaborative, with occupational therapy communicating needs and dietary staff responsible for assembling trays accordingly. However, staff acknowledged inconsistencies in the provision of adaptive equipment, and it was noted that the facility had a limited supply of certain items, such as only one 4-ounce nosey cup, which was not always available for the resident. The surveyor's review of the facility's policy on meal supervision and assistance further highlighted the expectation that trays be checked for correct diet, food consistency, and necessary adaptive devices before serving. Despite this policy, the resident did not consistently receive the adaptive equipment required for independent eating, as evidenced by repeated mismatches between the meal tray tickets and the items actually provided on the trays.
Failure to Notify Law Enforcement of Alleged Abuse
Penalty
Summary
The facility failed to notify law enforcement regarding an allegation of abuse involving a resident with severe cognitive impairment. On 4/20/25, a resident with diagnoses including dementia, chronic kidney disease stage 3, and spinal stenosis reported to an RN Supervisor that a CNA had pushed her. The CNA was immediately suspended pending investigation, and a body check revealed no injuries or discoloration. The facility's investigation included interviews with staff and other residents, and the resident was reinterviewed the following day but did not recall the incident. Despite the facility's policy requiring notification of law enforcement for all alleged violations involving abuse, the investigation documentation did not indicate that law enforcement was notified. The Nursing Home Administrator confirmed to the surveyor that police were not contacted because no injuries were observed on the resident. No further explanation was provided for the failure to report the allegation to law enforcement as required by facility policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure that residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice. Specifically, two residents, R43 and R19, were identified as not receiving appropriate pressure ulcer care. R43 was admitted with multiple pressure injuries, including an unstageable pressure injury to the right elbow, which worsened over time. The documentation for R43's wounds was inconsistent and lacked accurate descriptions of staging, measurements, and characteristics. Additionally, the care plan did not adequately address offloading or decreasing pressure on the elbow, leading to further deterioration of the wound. R43 also developed new pressure injuries to the left heel and right Achilles, which were not properly documented or managed according to the facility's policy and procedure for pressure ulcer management. The facility failed to notify the physician of changes in the wound's presentation and did not stage the wound accurately when the base was visible. The care plan was not updated to include recommendations from the wound clinic, and there were inconsistencies in the documentation of the left heel and right Achilles wounds. R43 was eventually transferred to the hospital for cardiac concerns and did not return to the facility during the survey. R19 was admitted with a Stage 3 pressure injury to the right outer ankle, which was not properly managed or documented. The wound did not show significant improvement, and the treatment orders remained unchanged despite the wound's deterioration. The facility failed to notify the physician of changes in the wound's presentation, and the documentation was inconsistent and inaccurate. The hospice RN involved in R19's care did not take measurements of the wound, relying on the facility's documentation, which was found to be inaccurate. The facility's failure to provide appropriate pressure ulcer care and accurate documentation led to the deficiency identified in the survey.
Failure to Thoroughly Investigate Allegation of Misappropriation
Penalty
Summary
The facility did not thoroughly investigate an allegation of misappropriation affecting a resident who reported a missing wallet. The wallet contained money, credit cards, insurance cards, and a driver's license. The Social Worker (SW) initiated an investigation by interviewing the resident's family members and staff who worked during the period when the wallet was last seen. However, the SW did not interview any other residents to determine if they had any knowledge of the missing wallet or if they had any personal items missing, which could have broadened the scope of the investigation. The SW acknowledged that they had overheard the resident discussing the missing wallet with other residents, but no further steps were taken to interview those residents. The Nursing Home Administrator (NHA) was informed of the concern that no other residents were interviewed to determine if the incident was isolated or if there was any additional information that could help discover what happened to the wallet. The NHA did not provide any further information at that time.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with 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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