Complete Care At Kensington
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukesha, Wisconsin.
- Location
- 1810 Kensington Dr, Waukesha, Wisconsin 53188
- CMS Provider Number
- 525242
- Inspections on file
- 24
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Complete Care At Kensington during CMS and state inspections, most recent first.
Surveyors identified that the facility failed to maintain an effective infection prevention and control program, including improper storage of garbage in PPE carts, use of a shared vital signs machine containing dirty linen and used tissues without disinfection, and inconsistent implementation of Enhanced Barrier Precautions for a resident on EBP orders. Staff entered and exited rooms and performed personal care and transfers without appropriate PPE or hand hygiene, including reusing gloves across tasks, contaminating clean linens during peri care, and leaving rooms without washing hands. Mechanical and Hoyer lifts used to transfer multiple residents were repeatedly returned to hallways or the shower room without being sanitized between residents, despite staff and leadership stating they should be cleaned after each use.
Several residents with existing or high risk for pressure injuries did not receive timely and comprehensive skin and wound assessments upon admission or when new wounds developed. In multiple cases, LPNs performed initial assessments without prompt RN follow-up, and wound documentation was delayed or incomplete. Staff failed to consistently implement or communicate offloading interventions, and air mattress settings were not properly adjusted. There was also confusion in wound care documentation and a lack of care plan updates for refusals, resulting in missed opportunities for effective pressure injury prevention and management.
Surveyors found that the facility did not provide required written notices to residents or their representatives regarding bed-hold policies, transfer/discharge reasons, or appeal rights during hospital transfers. Staff interviews revealed confusion about responsibilities, and documentation was inconsistent, with missing information about bed-hold payment rates and lack of written notification. The facility also failed to notify the Ombudsman of resident transfers or discharges, affecting multiple residents with complex medical needs.
Surveyors observed multiple failures in infection control practices, including staff not removing gloves or performing hand hygiene after providing incontinence care or emptying ostomy bags, and not wearing gowns during high-contact care for residents on enhanced barrier precautions. Staff also failed to change gloves and perform hand hygiene between dirty and clean tasks during wound care. These deficiencies were observed during care of residents with significant medical needs, such as indwelling catheters, chronic wounds, and severe cognitive impairment.
A resident with multiple medical conditions was found with a large bruise on the left eyelid, which was not witnessed by staff and could not be explained by the resident. Despite facility policy requiring reporting of injuries of unknown source, the incident was not reported to the State survey agency. Leadership relied on assumptions about the cause, such as difficulty with glasses, and did not complete required documentation or follow reporting protocols.
A resident with multiple medical conditions was found with a significant bruise to the left eyelid, first noticed by a family member. Although staff discussed possible causes, such as difficulty with glasses and use of a hoyer lift, the facility did not conduct a thorough investigation as required by policy, failing to interview all relevant staff or fully document the investigative process.
Two residents with significant medical needs were found to have excessively long toenails due to the facility's failure to ensure timely podiatry services, despite having signed consents and a policy requiring proper foot care. Staff interviews and record reviews revealed that both residents were not included on the podiatrist's list, and communication lapses with the podiatry group contributed to the deficiency.
Two residents did not receive appropriate bowel and bladder care, including lack of timely assessment, documentation, and intervention for incontinence and constipation. One resident experienced a decline in continence without a comprehensive assessment or individualized toileting plan, while another went several days without a bowel movement and did not receive interventions as outlined in the facility's protocol. Staff interviews revealed inconsistent documentation and lack of clarity regarding care protocols.
Three medication errors were identified, resulting in a medication error rate above 5%. Two residents did not receive medications as ordered: one did not receive Glimepiride before breakfast and was given the wrong eye drops, while another was administered a different eye drop product than prescribed. Nursing staff confirmed that medications should be given according to physician orders, but this was not followed in these cases.
The facility did not accurately submit required PBJ staffing data to CMS for a quarter, omitting agency staff hours and resulting in a one-star staffing rating and a flag for low weekend staffing. Review of schedules showed actual staffing was adequate, but the data submission process failed to capture all hours worked, potentially affecting all residents.
Failure to Maintain Effective Infection Control Practices for PPE, Hand Hygiene, and Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper hand hygiene, PPE management, and cleaning and disinfection of shared resident care equipment. Surveyors observed multiple PPE carts outside residents’ rooms containing garbage, including balled-up paper from used straws and cookie packaging stored in drawers with clean gowns and other PPE. A rolling vital signs monitor shared among 33 residents was found with dirty linen and used tissues with a dried red substance in its basket, with the blood pressure cuff, thermometer, and pulse oximeter resting on top of these soiled items. An LPN used this vital signs machine on a resident without noticing or removing the dirty linen and tissues and did not disinfect the blood pressure cuff before or after use; the LPN also used a manual blood pressure cuff from the nurse’s cart on the same resident and returned it without cleaning. The facility did not consistently implement Enhanced Barrier Precautions (EBP) and PPE use as ordered and as outlined in its policies. One resident with a history including infected left knee prosthesis, type 2 diabetes, primary hypertension, vitamin D deficiency, and stage 3 chronic kidney disease had a physician order for EBP, but there was initially no EBP signage or PPE storage outside the room, and the resident’s Kardex contained no indication of EBP or other precautions. The Infection Preventionist and a CNA exited this resident’s room without any discarded PPE evident, and the Infection Preventionist later acknowledged not knowing at the time that the resident was on EBP and that signage and a PPE cart were not in place until after the issue was recognized. CNAs subsequently transferred this resident with a mechanical lift without donning PPE, stating they were unaware of the precautions and did not see signage or PPE storage before entering; they also stated they did not believe transferring was a high-contact care activity requiring PPE, despite the EBP sign listing transferring as such. Hand hygiene and glove use practices during personal care were inconsistent with the facility’s handwashing policy. One CNA was observed entering a resident’s room wearing the same gloves used previously, touching environmental surfaces and equipment, assisting with clothing changes and transfers, leaving the room with the same gloves to obtain linens, and only later removing gloves and performing hand hygiene. During peri care for the same resident, the CNA contaminated clean linen by placing it in the sink, turning on the faucet, and using the soap dispenser pump with gloved hands before using the linen for the resident’s face. The same CNA was also seen exiting another resident’s room wearing gloves, retrieving clean linens from a hallway cart, and returning to the room without removing gloves or performing hand hygiene. In another case, during incontinence care for a resident with multiple sclerosis, diabetes, morbid obesity, and hypertension, one CNA removed gloves and left the room without hand hygiene, and the other CNA completed perineal care, applied barrier cream, and handled linens and equipment before removing gloves and leaving the room to retrieve a Hoyer lift without performing hand hygiene. The facility also failed to ensure proper cleaning and disinfection of mechanical lifts between residents, contrary to its policy that multiple-resident-use equipment be cleaned and disinfected after each use. Surveyors repeatedly observed CNAs using mechanical or Hoyer lifts to transfer several residents, including those dependent on chair/bed-to-chair transfers, and then placing the lifts in hallways or in the bath/shower room without sanitizing them. This occurred after transfers for multiple residents, including those with significant comorbidities such as diabetes, atrial fibrillation, and hypertensive heart disease with heart failure. Staff interviews revealed inconsistent understanding and practice: some CNAs stated lifts are only wiped down after use in rooms with precautions, others stated lifts are washed at night, while several staff members, including the Infection Preventionist and DON, stated that lifts should be sanitized after every use or when leaving the room. Despite these stated expectations, surveyor observations documented that lifts used for multiple residents were not disinfected between uses.
Failure to Provide Timely and Comprehensive Pressure Injury Assessment and Prevention
Penalty
Summary
Multiple deficiencies were identified in the facility's management of pressure injuries for several residents. In one case, a resident was admitted with a history of vertebral fractures, chronic kidney disease, heart failure, morbid obesity, and visual impairment. The hospital discharge summary indicated the presence of pressure injuries, but upon admission, only a Licensed Practical Nurse performed the initial skin assessment, noting abrasions and bruising. A comprehensive assessment by a Registered Nurse did not occur until five days later, despite the resident having two unstageable pressure injuries. Observations revealed that the resident's heels were not being offloaded as required, and the air mattress was set incorrectly for the resident's weight. Staff did not consistently communicate or implement offloading interventions, and there was a lack of timely and thorough wound assessment and documentation. Another resident with dementia, malnutrition, and spinal stenosis, who was also receiving hospice care, developed an open area on the right buttock. The hospice aide documented the wound, but no nursing assessment was completed for a week. The care plan included interventions such as offloading heels and using an alternating pressure mattress, but repeated observations showed the resident's heels were not being offloaded. There was also confusion and inconsistency in wound care documentation and dressing application, with a deep tissue injury on the sacrum being discovered without prior documentation or physician orders. The resident's care plan did not reflect refusals of care, despite documentation of resistance to repositioning and treatments. A third resident was admitted with a stage 4 sacral wound, but the initial admission assessment lacked a comprehensive description of the wound, including staging, wound bed, and surrounding tissue. The first detailed assessment was not completed until five days after admission by the wound doctor. Facility staff, including the wound nurse and unit manager, acknowledged that a comprehensive assessment should have been completed upon admission. Across all cases, the facility failed to ensure prompt and thorough assessment, documentation, and implementation of pressure injury prevention and management interventions, as required by their own policy and professional standards of practice.
Failure to Provide Required Written Bed-Hold Notices and Ombudsman Notification During Resident Transfers
Penalty
Summary
Surveyors identified that the facility failed to provide required written documentation and notifications related to bed-hold policies, transfer/discharge reasons, and appeal rights to residents and their representatives during hospital transfers or discharges. In all ten cases reviewed, there was no evidence that residents or their representatives received written notices specifying the reason for transfer/discharge or the facility's bed-hold policy, including the reserve bed payment rate for all payer sources after 15 days. Additionally, the facility did not notify the Ombudsman of these transfers or discharges as required by regulation and facility policy. The review of medical records and interviews with facility staff revealed inconsistent and unclear processes for completing and distributing transfer/discharge notices and bed-hold information. Staff members, including the Social Services Director, Medical Records Director, and Unit Secretary, provided conflicting accounts of their responsibilities, and there was confusion regarding who was responsible for notifying the Ombudsman. Documentation practices were inconsistent, with verbal consent often noted in place of written notification, and the required bed-hold payment rates were not included on the forms provided to residents or their representatives. In several instances, staff indicated that forms were only sent to representatives upon request, and there was no documentation that written notices were provided. The deficiency affected residents with a range of complex medical conditions, including seizures, neurogenic bowel, hemiplegia, diabetes, heart failure, chronic kidney disease, and others. Despite multiple hospital transfers for acute changes in condition, there was no evidence that the facility provided the necessary written information to residents or their representatives regarding their rights, the reason for transfer, or the financial implications of bed-hold policies. The facility also failed to maintain documentation of notifications to the Ombudsman for any of the reviewed cases.
Infection Control Deficiencies: Hand Hygiene, PPE, and Enhanced Barrier Precautions
Penalty
Summary
Multiple deficiencies were identified in the facility's infection prevention and control practices, particularly regarding hand hygiene, glove use, and adherence to enhanced barrier precautions (EBP). Staff were observed failing to remove gloves and perform hand hygiene after providing incontinence care, emptying ostomy bags, and before touching clean surfaces or equipment. For example, after emptying a resident's ileostomy bag, a staff member did not remove gloves or perform hand hygiene before turning on the resident's radio. In another instance, a staff member did not remove gloves or wash hands after providing incontinence care, only performing hand hygiene at the end of the care process. There were also failures to use appropriate personal protective equipment (PPE) as required by the facility's EBP policy. Staff were observed not wearing gowns when providing high-contact care activities, such as transferring, changing linens, and providing hygiene to residents on EBP, including those with indwelling urinary catheters or chronic wounds. In one case, a staff member entered a resident's room on EBP, delivered meal trays, and left the room without performing hand hygiene as required by posted signage and facility policy. Additionally, a nurse was observed performing wound care without changing gloves and performing hand hygiene between dirty and clean tasks, contrary to accepted standards and state guidance. The residents involved had significant medical needs, including severe cognitive impairment, incontinence, indwelling urinary catheters, chronic wounds, and pressure ulcers. The observed lapses in infection control occurred during routine care activities such as incontinence care, wound care, catheter care, and assistance with activities of daily living. These actions and inactions were directly observed by surveyors and confirmed through interviews with facility staff, who acknowledged the required procedures were not followed in these instances.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident who was found with a significant bruise covering almost the entire left eyelid. The incident was first brought to staff attention by the resident's daughter, who noticed the bruise and believed it may have been caused by the resident resting his face against a hoyer sling during transfers. Nursing staff documented the bruise, noting its size and location, and that the resident was cognitively intact, denied pain, and could not recall how the injury occurred. Multiple staff members and the resident's representative provided differing accounts regarding the possible cause, including difficulty with glasses and the use of the hoyer lift, but no definitive cause was established. Despite the facility's policy requiring the reporting of all injuries of unknown source to the State survey agency, the incident was not reported. The policy specifically lists physical injury of unknown source as a possible indicator of abuse and mandates reporting within specified timeframes. Interviews with facility leadership revealed that the Nursing Home Administrator did not consider the injury to be of unknown origin, citing the resident's use of glasses as a likely explanation, and did not complete the required injury of unknown source flowchart to document the decision-making process. Surveyor review confirmed that the injury was not observed by staff, the resident could not recall the cause, and the location of the bruise was not generally vulnerable to trauma. The facility did not provide additional documentation or policies to justify the decision not to report. The lack of reporting was based on subjective judgment rather than adherence to the facility's written policy and regulatory requirements.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an injury of unknown source for one resident. The resident, who had diagnoses including diabetes mellitus, urinary retention, metabolic encephalopathy, bladder cancer, hypertension, and depression, was observed with a bruise covering almost the entire left eyelid. The bruise was first brought to staff attention by the resident's daughter, who noticed it prior to staff awareness. Documentation indicated that the resident was cognitively intact and used a hoyer lift for transfers. Staff and family noted the resident sometimes rested his face against the hoyer sling and had difficulty putting on his glasses, often hitting his face in the process. Despite the facility's policy requiring immediate and thorough investigation of injuries of unknown source, the investigation into the resident's bruise was incomplete. While some staff, such as the LPN/Unit Manager, DON, and a Med Tech, were involved in discussions and provided statements, there was no evidence that all staff who provided care to the resident on the days surrounding the appearance of the bruise were interviewed. The investigation relied on verbal statements and did not include written statements from all relevant staff, nor did it document interviews with all potential witnesses or caregivers who may have had knowledge of the incident. The facility's documentation included notes from nursing staff, the interdisciplinary team, and the resident's representative, but lacked comprehensive evidence of a systematic investigation as outlined in facility policy. The surveyor found that the information provided did not demonstrate a thorough investigation into the cause of the injury, as required by the facility's own procedures for responding to alleged violations, including injuries of unknown source.
Failure to Provide Timely and Appropriate Foot Care
Penalty
Summary
Two residents were found to have excessively long toenails that required trimming, indicating a failure by the facility to provide appropriate foot care as outlined in their own policy. Both residents had signed podiatry consent forms on file, but there was no documentation that either had received podiatry services since admission. One resident had a diagnosis of diabetes mellitus, which can complicate foot care needs, while the other had dementia. Observations by the surveyor confirmed that both residents' toenails were very long and in need of attention. Interviews with staff revealed that the process for scheduling podiatry services was not consistently followed. The unit secretary explained that residents are added to the podiatrist's list after consent forms are signed, but acknowledged that both residents were not included on the list for podiatry visits. The podiatrist had previously visited the facility during early morning hours, and there were concerns that some residents were reported as seen when they were not, as confirmed by resident feedback. The unit secretary also reported communication issues with the podiatry group, including missed emails and lack of follow-up. Medical record review and staff interviews confirmed that despite the presence of signed consents, neither resident had documentation of receiving podiatry care. In one case, a nurse assessed a resident's toenails and determined they were too thick and difficult to trim safely, but no podiatry service had been provided up to that point. The lack of timely and appropriate foot care for both residents constituted a deficiency in meeting their care needs as required by facility policy.
Failure to Provide Appropriate Bowel and Bladder Care and Assessment
Penalty
Summary
Two residents did not receive appropriate treatment and services to restore or maintain bowel and bladder continence, as required by facility policy and regulatory standards. One resident experienced a significant decline in continence status without a comprehensive assessment or individualized toileting plan. Despite documentation in the care plan to conduct a three-day bladder diary and assessment on admission, quarterly, annually, and with significant change, there was no evidence that such assessments or a voiding pattern study were completed after the resident's decline. Staff interviews confirmed that there was no set toileting schedule beyond routine checks, and the LPN Unit Manager was unaware of the decline documented in the MDS. The resident was observed managing incontinence independently, sometimes without staff assistance, and at high risk for falls due to not locking wheelchair brakes and not using the call light. Another resident, with a history of neurogenic bowel, hemiplegia, and severe cognitive impairment, went six days without a documented bowel movement. The care plan included interventions such as monitoring and documenting bowel movements every shift and following a protocol for no bowel movement for three days, but these interventions were not implemented. Bowel documentation was inconsistent, with multiple shifts left blank and no PRN bowel medications administered during the period of constipation. The resident was eventually sent to the hospital for an unrelated change of condition and was diagnosed with a small bowel obstruction. Staff interviews revealed confusion about documentation codes and the bowel protocol, and the facility was unable to provide clear evidence of monitoring or interventions during the period of constipation. The facility's failure to follow its own policies and protocols for bowel and bladder management, including timely assessment, documentation, and intervention, resulted in residents not receiving appropriate care. The lack of comprehensive assessment and individualized care planning, as well as inconsistent documentation and unclear staff understanding of protocols, contributed to the deficiencies identified by surveyors.
Medication Error Rate Exceeds 5% Due to Incorrect Administration and Product Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with three medication errors identified out of 28 opportunities, resulting in a 10.71% error rate. Two errors involved one resident who did not receive Glimepiride 4 mg before breakfast as ordered by the physician and was also administered the incorrect eye drop medication. Specifically, the resident received artificial tears lubricant eye drops instead of the prescribed Systane Ophthalmic Solution, and the Glimepiride was not given prior to breakfast as directed in the physician's order. These errors were observed during medication administration and confirmed through review of the resident's medical records and physician orders. A third medication error involved another resident who was administered Visine dry eye relief lubricant instead of the prescribed Artificial Tears Solution 1.4% (Polyvinyl Alcohol). The error was observed during the medication pass and later verified by comparing the administered medication to the physician's order. Interviews with nursing staff confirmed that medications are expected to be administered according to physician orders, including timing and specific products, but these expectations were not met in the observed instances.
Failure to Accurately Submit Staffing Data to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate electronic submission of direct care staffing information to CMS for Quarter 1 (October 1 - December 31) as required by federal regulations. The Payroll Based Journal (PBJ) data submitted did not accurately reflect all staffing hours, specifically omitting agency staff hours for the month of October. This omission resulted in the facility being flagged for excessively low weekend staffing and receiving a one-star staffing rating for the quarter. Review of the facility's weekend schedules and staffing ratios did not reveal discrepancies in actual staffing, indicating the issue was with the data submission rather than actual staffing levels. Interviews with the scheduler and the nursing home administrator revealed that staffing data is pulled directly from the timekeeping system and reported to CMS, but the omission of agency staff hours was not initially detected. The administrator confirmed that corporate oversight identified the missing data, and the director of nursing and unit managers were noted to assist with staffing when census was high. The deficiency had the potential to affect all 69 residents in the facility, as accurate staffing data is essential for regulatory compliance and quality monitoring.
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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