Complete Care At Jefferson Meadows Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baraboo, Wisconsin.
- Location
- 1414 Jefferson St., Baraboo, Wisconsin 53913
- CMS Provider Number
- 525317
- Inspections on file
- 16
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Jefferson Meadows Llc during CMS and state inspections, most recent first.
Three residents did not receive adequate nutrition and hydration due to the facility's failure to monitor and document fluid and food intake, update care plans and assessments after significant changes in condition, and communicate with the physician or registered dietitian as required. One resident suffered actual harm, including hospitalization for severe dehydration, while two others experienced significant weight loss and inconsistent monitoring of their nutritional needs.
Dietary staff were observed handling food with bare hands and without performing hand hygiene, as well as entering food service areas without required hair restraints. These actions violated facility policy and were confirmed as unacceptable by dietary staff and management.
Surveyors observed that six expired stock antibiotic ointments, including bacitracin zinc and triple antibiotic ointments, were present in the medication room. The DON confirmed these medications were expired and should not have been available, indicating a failure to follow facility policy for medication storage and removal of outdated drugs.
Surveyors identified that multiple residents did not have documentation of MD or NP visits in their medical records, either in the EHR or paper charts. Staff interviews revealed inconsistent access to and retrieval of visit notes, with some staff not regularly checking the EHR and others lacking access altogether. Facility policies requiring tracking and documentation of physician visits were not consistently followed, resulting in incomplete and inaccessible medical records.
The facility did not follow its antibiotic stewardship protocols by failing to verify infection criteria and monitor symptoms and treatment effectiveness for several residents started on antibiotics for UTIs and pneumonia. Required documentation of infection assessment and ongoing monitoring was missing, despite staff stating that such protocols were in place.
The facility did not complete or maintain required PASRR Level I and Level II screenings for two residents with mental health diagnoses. For one resident, no PASRR Level I was found, and for another, a PASRR Level II was missing despite a Level I with a 30-day exemption. The social worker and DON confirmed the absence of necessary documentation and acknowledged that PASRRs should be completed and kept in the medical record.
A resident with severe cognitive impairment was repeatedly observed without meaningful activities, spending most days napping or roaming the halls. Despite a care plan outlining the need for therapeutic recreation and staff support, the facility did not consistently provide individualized activities or adequate documentation of participation, resulting in unmet physical, mental, and psychosocial needs.
A resident with severe cognitive impairment and malnutrition, who was receiving nutrition and medication via G-tube, did not have proper verification of tube placement prior to feeding. Nursing staff checked placement using only air, omitting the required aspiration of gastric contents as outlined in facility policy and the care plan. Both the nursing supervisor and DON confirmed that aspiration should have been performed.
A registered nurse was observed crushing and preparing to administer extended-release Levetiracetam tablets to a resident with epilepsy, contrary to facility policy and manufacturer instructions that prohibit crushing such medications. The nurse assumed all medications should be crushed due to the resident's swallowing difficulties, but the resident's chart did not specify this. The error was identified by surveyors before administration.
Two residents receiving hospice care did not have their current hospice plans of care available to facility staff, despite facility policy requiring coordination and documentation. Staff interviews revealed inconsistent processes for obtaining and reviewing hospice care plans, and documentation was limited to team listings and visit logs without substantive care information. The hospice plans of care were not found in the residents' charts or hospice binders, and staff had to request them from external sources.
A resident with moderate cognitive impairment and a history of trauma was repeatedly subjected to verbal abuse, including yelling and profanity, by her activated POA. Despite multiple incidents witnessed and reported by staff, the facility did not implement or document specific interventions in the care plan or Kardex to prevent further abuse or ensure the resident's safety during visits. Staff awareness of the situation and required actions was inconsistent, and the facility failed to ensure effective measures were in place to protect the resident from ongoing verbal abuse.
Staff failed to immediately intervene when a resident was subjected to alleged verbal abuse by her POA, despite overhearing loud yelling and profanity. The CNA and RN reported the incident to the DON but did not enter the room or ensure the resident's immediate safety. The resident, who had cognitive impairment and was identified as vulnerable to abuse, was found crying after the incident. Staff interviews indicated uncertainty about specific interventions and a lack of immediate protective action during the event.
A resident with moderate cognitive impairment, a history of trauma, and recent bereavement did not have a comprehensive, person-centered care plan that incorporated behavioral health recommendations for grief and trauma support. Despite receiving behavioral health services and having specific interventions recommended by psychology, these were not included in the care plan, and staff were not fully informed of the resident's trauma history.
The facility did not monitor or document water heater and hot water storage tank temperatures as required by its infection prevention and control program, leaving it unable to demonstrate compliance with national standards for minimizing Legionella risk. Interviews with maintenance staff and the administrator confirmed the absence of temperature logs, despite policy requirements and a work order system intended for regular checks. This deficiency had the potential to impact all residents in the facility.
A facility failed to assess the risks of using side rails with air mattresses, leading to a resident's entrapment and subsequent death. The resident, with severe dementia and reduced mobility, was not properly assessed for entrapment risks when their mattress was changed to a Panacea Convertible Mattress with powered alternating-pressure therapy. The facility did not document alternatives to side rails or provide updated risk information to the resident's Health Care Power of Attorney. This oversight resulted in immediate jeopardy findings.
Failure to Ensure Adequate Nutrition and Hydration for Multiple Residents
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for three residents, resulting in one resident experiencing actual harm and two others being placed at risk for more than minimal harm. For one resident with severe dementia, the facility did not total or assess daily fluid intake, failed to accurately assess and document ongoing signs and symptoms of dehydration, and did not update care plans or nutritional assessments after a significant change in condition that led to hospitalization for severe hypernatremia and dehydration. Despite clear evidence of declining intake and physical changes, there was no documentation of interventions attempted or communication with the registered dietitian prior to the hospitalization. Staff interviews confirmed that the resident required assistance and encouragement to eat and drink, but this was not consistently documented or reflected in updated care plans. Another resident experienced significant weight loss, but the facility did not appropriately notify the physician or nurse practitioner, started a nutritional supplement without a physician's order, and failed to monitor the amount of supplement consumed. The dietary assessment for this resident had not been updated in over a year, and there was no comprehensive documentation of calorie, protein, or hydration needs. Staff interviews revealed confusion about the process for supplement administration and tracking, and the resident reported dissatisfaction with the food and lack of snacks. A third resident's fluid intake was not monitored, and the physician was not notified of a severe weight loss of 10% over two weeks. The resident's favorite beverage was not added to the care plan as required by facility policy, and a complete nutrition assessment by the registered dietitian was not conducted. Documentation of fluid intake was inconsistent, and the resident was not consistently offered snacks. Facility policies required systematic assessment, monitoring, and documentation of hydration and nutrition, but these were not followed for the residents reviewed.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
Surveyors observed that dietary staff failed to follow safe and sanitary food handling practices during food preparation and service. Specifically, staff were seen directly touching sausage and the inside lip of fruit cups with their bare hands, without wearing gloves or performing hand hygiene. Additionally, staff entered the kitchen and food service area without wearing required hair restraints while food service was ongoing. These actions were in direct violation of the facility's Food Safety Requirements policy, which mandates the use of gloves, tongs, or other barriers when handling food and requires hair restraints in food preparation and service areas. Interviews with dietary staff and the dietary manager confirmed that these practices were not acceptable and were contrary to established policy.
Expired Antibiotic Ointments Found in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional standards in the medication room. During an observation with the Director of Nursing (DON), six expired stock antibiotic ointments were discovered, including three bacitracin zinc ointments and three triple antibiotic ointments (bacitracin zinc/neomycin sulfate/polymyxin B sulfate), all past their expiration dates. The expired medications were present in the medication storage room, contrary to facility policy and professional guidelines. The facility's policy requires that all medications be stored according to manufacturer recommendations and that discontinued, outdated, or deteriorated medications be routinely inspected and destroyed as appropriate. However, the presence of these expired ointments indicated that the required inspections and removals had not been adequately performed. The DON confirmed during interview that the expired creams should not have been in circulation and verified their expired status.
Failure to Maintain and Document MD/NP Visit Notes in Resident Medical Records
Penalty
Summary
Surveyors found that the facility failed to maintain complete, accurate, and readily accessible medical records for all residents reviewed. Specifically, for 13 residents, there was no documentation of routine or acute visits by medical doctors (MD) or nurse practitioners (NP) in either the electronic health record (EHR) or paper charts. This lack of documentation was discovered during a review of records and interviews with staff, who confirmed that visit notes were not regularly obtained or filed in the residents' records. Facility policies require licensed nurses to track physician visit due dates, remind physicians to document visits, and for the Director of Nursing or designee to conduct monthly audits for timeliness. Additionally, all assessments, observations, and services provided are to be documented in accordance with state law and facility policy. Despite these policies, staff interviews revealed inconsistent practices regarding access to and retrieval of MD/NP visit notes. Some staff had access to the EHR but did not check it regularly, while others lacked access entirely and relied on supervisors for information. Further interviews with the Nursing Supervisor, RNs, LPNs, the Nursing Home Administrator, and Medical Records staff indicated a lack of clarity and consistency in responsibility for obtaining and tracking MD/NP visit documentation. The Medical Records staff acknowledged that a comprehensive review had not been conducted recently, and that obtaining visit notes had not been consistently performed. As a result, the facility did not have the required MD/NP visit notes readily accessible in the health records for the residents reviewed.
Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
The facility failed to follow its own antibiotic stewardship program and standards of practice for monitoring antibiotic use, as evidenced by the lack of verification that infection criteria were met and insufficient monitoring of symptoms and treatment effectiveness for several residents started on antibiotics. The policy required nursing staff to assess residents suspected of infection, verify infection criteria (such as McGeer's Criteria), and document both the initiation and ongoing monitoring of antibiotic therapy, including an antibiotic timeout within 48-72 hours. However, for multiple residents, there was no documentation that these steps were followed. One resident with a history of cystitis and chronic kidney disease was started on antibiotics for urinary symptoms, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of treatment during and after the antibiotic course. Another resident with encephalopathy and failure to thrive was prescribed antibiotics for a UTI, but there was no documentation of infection criteria assessment or monitoring of symptoms and treatment response. Similarly, a resident with multiple sclerosis and overactive bladder was started on antibiotics for a UTI based on staff observations and lab results, but again, there was no documentation of infection criteria review or monitoring of symptoms before or after starting antibiotics. Additionally, a resident with chronic obstructive pulmonary disease and paroxysmal atrial fibrillation was treated for pneumonia after a chest x-ray, but the facility did not document whether infection criteria were met or monitor symptoms and effectiveness of antibiotic treatment. Interviews with facility staff confirmed that while McGeer's Criteria were referenced, there was no documentation of their use, and no evidence of required monitoring or assessment was found in the records. The facility's failure to document these critical steps led to the deficiency.
Failure to Complete and Document Required PASRR Screenings
Penalty
Summary
The facility failed to follow the required Preadmission Screening and Resident Review (PASRR) process for two residents. For one resident with diagnoses including dementia, depression, and mood disorder, there was no documentation of a PASRR Level I screening being completed prior to admission, as required by facility policy and Medicaid rules. The social worker confirmed that no PASRR documentation could be found for this resident, indicating that the initial screening step was missed. For another resident with diagnoses such as delusional disorders, restlessness, and agitation, a PASRR Level I was submitted with a 30-day exemption, but there was no documentation of a required PASRR Level II evaluation. The social worker was unable to provide evidence that the Level II evaluation had been completed, and the Director of Nursing confirmed that PASRRs should be completed timely and maintained in the resident's medical record. These lapses demonstrate that the facility did not ensure the appropriate PASRR steps were followed and documented for residents with mental disorders or intellectual disabilities.
Failure to Provide Individualized Activity Program for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of a resident with severe cognitive impairment. Observations over multiple days showed the resident sitting in a hallway, often staring at a wall, with no meaningful activities offered. Documentation from January to May indicated the resident primarily napped or roamed the halls, with minimal participation in activities such as family visits, animal therapy, or group events. The resident's care plan specified the need for therapeutic recreation, including weekly one-on-one visits, group activities, and the provision of comfort items like baby dolls, but these interventions were not consistently implemented. Interviews with staff revealed that the resident was unable to structure her own leisure time and required staff support to attend activities. Staff acknowledged that activity documentation lacked details on duration, participation level, and enjoyment, and that alternative activities were not offered if the resident was napping during scheduled events. The activity director confirmed that the resident enjoyed sensory activities, music, and outdoor time, but required assistance to access these opportunities. Despite these identified needs and preferences, the facility did not ensure an ongoing, individualized activity program for the resident.
Failure to Properly Verify G-Tube Placement Prior to Feeding
Penalty
Summary
A deficiency occurred when a resident receiving nutrition and medication via a G-tube did not receive appropriate treatment and services as required by facility policy and the resident's care plan. The facility's policy and the resident's care plan both required that tube placement be verified before each feeding and medication administration by both auscultation and aspiration of gastric contents. However, during observation, a registered nurse checked the G-tube placement using only air and did not aspirate gastric contents prior to administering the tube feeding. The nurse acknowledged in an interview that she typically does not aspirate gastric contents, despite knowing it is required. Further interviews with the nursing supervisor and the director of nursing confirmed that their expectation is for staff to both listen for air flow and aspirate gastric contents when checking G-tube placement. The resident involved had significant cognitive impairment, severe protein-calorie malnutrition, and was at risk for complications related to tube feeding. The failure to follow established protocols for verifying tube placement and aspirating gastric contents prior to feeding constituted a deficiency in care for this resident.
Crushing of Extended-Release Medication by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) prepared to administer medications to a resident diagnosed with generalized idiopathic epilepsy and epileptic syndromes. The RN was observed crushing seven medications, including two tablets of Levetiracetam ER (an extended-release anticonvulsant), despite facility policy and manufacturer instructions that specifically prohibit crushing extended-release medications. The facility's policy requires medications to be administered as ordered and in accordance with manufacturer specifications, including not crushing medications labeled as 'do not crush.' The RN admitted to crushing the Levetiracetam ER tablets based on an assumption that the resident, who had a history of stroke and difficulty swallowing, required all medications to be crushed. The resident's chart did not specify administration instructions for these medications. The error was identified by surveyors before the medications were administered, and the RN acknowledged that she would not have caught the error without their intervention.
Failure to Ensure Hospice Plan of Care Availability and Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice providers for two residents receiving hospice care. For both residents, the current hospice plan of care was not available to facility staff, despite the facility's policy requiring coordination and documentation of hospice interventions. Interviews with nursing staff, including the RN, Nursing Supervisor, MDS/Infection Preventionist, and DON, revealed inconsistent understanding and execution of processes for obtaining, reviewing, and integrating the hospice plan of care into the facility's records. Staff were either unaware of the location of the hospice plan of care or stated that it was not provided or reviewed, and documentation in the hospice communication binder was limited to team listings and visit logs without substantive care information. One resident had diagnoses including corticobasal degeneration, Alzheimer's disease, and was receiving palliative care. The facility's care plan referenced hospice involvement and directed staff to see the hospice plan of care, but this document was not found in the resident's chart or the hospice binder. Staff interviews confirmed that the hospice plan of care was not reviewed or integrated into the facility's care planning process, and the designated hospice liaison did not review the hospice plan of care. The second resident, with a history of hemorrhagic stroke, quadriplegia, and vascular dementia, was also receiving hospice care. The resident's care plan included interventions to coordinate with hospice and notify them of changes, but the hospice plan of care was not present in the paper chart, electronic medical record, or hospice binder. Facility staff had to request the hospice plan of care from an external electronic health record, indicating a lack of immediate access and integration. The DON confirmed the expectation that the facility should review and align the hospice plan of care with the facility's plan, but this was not occurring.
Failure to Protect Resident from Repeated Verbal Abuse by POA
Penalty
Summary
A resident with moderate cognitive impairment and a history of childhood abuse was subjected to repeated verbal abuse by her activated Power of Attorney (POA) while at the facility. The POA was reported to have yelled, used profanity, and displayed aggressive behavior toward the resident on multiple occasions, including incidents where staff overheard loud, profane language and observed the resident crying. Despite these events, the facility did not implement or document specific interventions to prevent further verbal abuse or to ensure the resident's safety during visits from the POA. The resident's care plan and Kardex did not include any interventions or increased monitoring related to the POA, even though the facility's policies defined verbal abuse and allowed for visitation restrictions in cases of emotionally harmful behavior. Staff interviews revealed a lack of awareness regarding any interventions or special precautions for the resident when the POA was present. While some staff were aware of a memo at the nurse's station instructing them to report any yelling by the POA, this information was not consistently communicated to all staff, including new or agency staff, and was not reflected in the resident's care documentation. Multiple staff members, including CNAs, nurses, and support staff, acknowledged hearing or being aware of the POA's verbally abusive behavior toward the resident. However, there was inconsistency in staff responses, with some not intervening or being unclear about the appropriate actions to take. The facility leadership chose not to document interventions in the care plan or Kardex, citing concerns about the POA's access to these documents. As a result, the facility failed to ensure that effective measures were in place to protect the resident from ongoing verbal abuse by the POA.
Failure to Immediately Intervene During Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to immediately intervene when staff heard alleged verbal abuse directed at a resident by her power of attorney (POA). Staff, including a CNA and an RN, overheard loud yelling and profanity coming from the resident's room, with the POA using explicit language and raising her voice. The CNA reported the incident to the nurse, who then notified the Director of Nursing (DON), but neither staff member entered the room or directly intervened to ensure the resident's immediate safety at the time the abuse was occurring. The resident involved had a history of cognitive impairment, including dementia and mood disorders, and was identified as vulnerable to abuse in her care plan. When the DON and Nursing Home Administrator (NHA) entered the room, the POA's behavior de-escalated, but the resident was observed crying. The resident stated she felt safe with her POA and wanted visits to continue, but staff and social services confirmed that this was not the first time the POA had yelled at the resident. Despite the facility's abuse prevention policy requiring immediate protection and intervention for residents at risk, staff did not act promptly to protect the resident during the incident. Staff interviews revealed that while there had been recent education on abuse reporting, the CNA and RN did not physically check on the resident or intervene during the altercation, instead relying on reporting the incident up the chain of command. The care plan and other documentation did not include specific interventions for staff to follow in such situations, and staff were uncertain about what measures were in place to keep the resident safe during and after such incidents.
Failure to Develop Person-Centered Care Plan for Behavioral Health Needs
Penalty
Summary
A deficiency was identified when the facility failed to comprehensively assess and develop a person-centered care plan for a resident experiencing ongoing grief and sadness following the recent loss of her son, as well as past trauma. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and other behavioral and emotional disorders, was found to be moderately cognitively impaired and had an activated power of attorney. Despite receiving behavioral health services and having a documented history of significant trauma and recent bereavement, the facility did not incorporate recommended interventions from behavioral health professionals into the resident's care plan. The resident's trauma screening assessment revealed a history of physical and sexual abuse, life-threatening illness, severe human suffering, and the sudden, unexpected death of someone close. A psychology appointment documented maladaptive behavioral symptoms, emotional distress, and specific recommendations for care, such as increasing positive emotions, integrating faith-based support, encouraging socialization, and providing validation during episodes of grief. However, these recommendations were not reflected in the resident's comprehensive care plan or Kardex, which only included general statements about encouraging activity participation and observational behavior monitoring. Interviews with facility staff, including the Nursing Home Administrator and Director of Social Services, confirmed that the recommended interventions from behavioral health were not care planned and that staff were not fully aware of the specifics of the resident's trauma. Observations showed the resident was tearful and withdrawn, and while she reported some support from nursing staff, the lack of a comprehensive, individualized care plan addressing her grief and trauma constituted a failure to provide necessary behavioral health care and services.
Failure to Monitor Water Heater Temperatures per Infection Control Policy
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required by policy and national standards. Specifically, the facility did not monitor or document the temperature of the water heater (WH) or hot water storage tank (HWT) as outlined in their Water Management Program. The program required that water heater and storage tank outlet temperatures be maintained at or above 140 degrees Fahrenheit to prevent the growth of Legionella and other waterborne pathogens. Interviews with the Maintenance Director and Maintenance Tech revealed that while there was a work order in the maintenance management system to check water temperatures monthly, no records or logs of temperature readings could be found. The new Maintenance Director confirmed that there was no documented monitoring of the WH or HWT temperatures. Further, the Nursing Home Administrator acknowledged that a previous maintenance director had implemented a robust plan for temperature testing, but no documentation could be produced to verify ongoing monitoring or compliance with the facility's water management protocols. The lack of documented temperature monitoring meant the facility could not demonstrate that control measures were being followed to minimize the risk of Legionella and other pathogens, as required by their infection prevention and control policy and national guidelines. This deficiency had the potential to affect all 48 residents residing in the facility.
Failure to Assess Risks of Side Rails with Air Mattresses
Penalty
Summary
The facility failed to ensure that alternatives were tried before installing and utilizing side rails for residents, particularly those using an air mattress. This oversight was evident in the case of a resident who was admitted with severe dementia, reduced mobility, osteoporosis, and cerebrovascular disease. The facility implemented the use of side rails without assessing the risks associated with combining them with an air mattress, which increases the risk of entrapment. The resident became entrapped in the side rail, resulting in multiple fractures and subsequently passed away the following day. The facility did not conduct a proper assessment for entrapment risks when changing the resident's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy. Additionally, the facility failed to provide new risk and benefit information to the resident's Health Care Power of Attorney when the mattress was changed. The facility's Bed System Measurement Device, which is not recommended for use with alternating air mattresses, was used without proper documentation, and quarterly bed/side rail measurement tests were not completed as per facility policy. The deficiency was further highlighted by the facility's failure to document any alternatives attempted before utilizing bed rails for other residents. The facility did not provide evidence of alternative interventions being tried prior to the installation of bed rails for other residents using similar air mattresses. This lack of assessment and documentation contributed to the finding of immediate jeopardy, as the facility did not recognize the increased risk of entrapment posed by the combination of side rails and air mattresses.
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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