Complete Care At Maple Grove Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 3401 Maple Grove Dr., Madison, Wisconsin 53719
- CMS Provider Number
- 525276
- Inspections on file
- 27
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Complete Care At Maple Grove Llc during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not specify further details.
Three residents at the facility did not receive fall interventions as outlined in their care plans, nor adequate supervision to prevent accidents. One resident with a history of frequent falls, including a head injury, was not provided increased supervision despite repeated incidents in similar settings. Another resident was observed ambulating without her walker and lacked the required reminder signage. A third resident with wandering and behavioral issues was not given additional supervision to prevent entry into other residents' rooms, increasing the risk of altercations.
Staff did not consistently follow professional standards for food service safety, as a dietary aide failed to allow the thermometer to dry after sanitizing before checking food temperatures and did not check all required food items, including ground and pureed foods. The dietary manager confirmed that all food temperatures should be taken and that the thermometer should be dry before use, but these practices were not followed.
Several residents reported that a cognitively impaired resident repeatedly entered their rooms uninvited, sometimes sitting on their beds or in their wheelchairs, and in one instance, causing pain by sitting on a recent surgical site. Staff were aware of the ongoing intrusions and attempted redirection and other interventions, but these were not effective in preventing the behavior. The facility did not implement measures to stop the unwanted entries, resulting in a failure to protect residents' dignity and privacy.
Surveyors found that multiple medications, including PRN and as-needed drugs, were expired or lacked proper labeling such as open dates on a medication cart. An LPN confirmed that medications should be checked for expiration before administration and that expired drugs should be discarded. The DON reported that the pharmacist is responsible for auditing medication carts and rooms, but checks may only occur monthly and require advance scheduling. These findings indicate that the facility did not consistently follow its own policy for medication storage and labeling.
A resident with multiple medical conditions, including arthritis and macular degeneration, was observed with medications left at the bedside for self-administration without a completed assessment or physician order. Staff left medications based on the resident's preference, but documentation and interviews revealed the resident could not identify her medications and had recently needed assistance. The required assessment process was not followed prior to allowing self-administration.
A resident raised concerns about staff using personal cell phones during work hours, but the facility did not document or investigate the grievance as required by policy. Surveyors observed multiple LPNs using cell phones for personal matters, and the resident reported no follow-up on her complaint. The grievance was not entered into the log, and the required investigation and resolution steps were not completed.
A resident with moderate cognitive impairment and mobility needs was repeatedly observed seated in a Broda chair with the brakes engaged, preventing self-movement. The brakes were positioned out of the resident's reach, and staff interviews confirmed that this restricted the resident's freedom of movement, meeting the facility's definition of a physical restraint. The care plan did not indicate a medical need for this restraint.
Three residents did not have their individual needs and preferences addressed in their care plans, including one resident whose care plan for interpreter services was not followed, and two residents whose religious practices as Muslims were not included in their care plans. Staff were unaware of the residents' language or religious requirements, and facility policy requiring person-centered, culturally competent care planning was not met.
A resident with moderate cognitive impairment and multiple medical conditions expressed a desire to move to assisted living, but the care plan continued to reflect a long-term stay in the facility. Although the social worker was aware of the resident's goal and began working on placement, the care plan was not updated to match the resident's current wishes, as confirmed by both the SW and DON.
Two residents who are practicing Muslims did not have their religious and cultural needs accommodated, as their care plans failed to reflect their preferences for prayer and cleanliness. Both residents reported being unable to practice their faith as required, and staff interviews revealed a lack of awareness or incorrect information about their religious needs. Facility policies requiring person-centered care and respect for resident choices were not followed.
Two residents who were dependent on staff for ADL support did not receive timely assistance with personal hygiene, grooming, and toileting as required by their care plans. One resident was repeatedly observed with unkempt hair and long whiskers, while another was left in urine-soaked clothing for extended periods. Staff interviews and documentation revealed inconsistent care and a lack of adherence to facility policies, resulting in compromised dignity and unmet care needs.
A resident with a stage 4 pressure injury did not receive care as ordered by the physician, including required repositioning and time limits in a wheelchair. Staff were unaware of the specific repositioning schedule, and the care plan and care card did not reflect the individualized orders. The resident was observed remaining in her wheelchair beyond the allowed time without repositioning, and the facility could not provide a pressure injury care policy when requested.
A resident with chronic pain and multiple medical conditions experienced ongoing pain during transfers with an EZ stand lift, despite repeatedly expressing discomfort and requesting alternative methods. Facility staff and leadership were aware of the resident's pain, but did not reassess her pain management plan, update her care plan, or implement new transfer approaches, resulting in continued daily pain.
A resident with a history of falls and cognitive impairment experienced multiple falls from a lift chair, including one resulting in a femur fracture, after the facility failed to assess the resident's ability to safely use the chair and did not provide adequate supervision or staff education on fall prevention.
A resident with a physician-ordered Level 7: Easy to Chew diet was regularly provided with snacks such as cheese crackers, Cheetos, and potato chips by staff and family, despite these items not being compliant with her prescribed diet. Staff, including a speech therapist, allowed these exceptions for quality of life reasons but did not document them or update the care plan. The registered dietician and DON confirmed that these exceptions were not communicated or recorded in the resident's medical record.
A resident's medical record contained conflicting care plan entries regarding their ability to self-administer medication, with some documentation allowing self-administration and other entries prohibiting it and requiring observation. Staff interviews revealed confusion about the resident's self-medication status, and no physician order authorizing self-administration was found in the EMR. The DON acknowledged the conflicting information in the care plan.
The facility failed to properly install and test bed rails for four residents, leading to potential safety risks. Bed rails were installed without conducting necessary tests to ensure proper installation and reduce entrapment risks. The Maintenance Supervisor admitted that a new employee, untrained in using the measurement device, was installing bed rails, and several installations had not been tested. The Nursing Home Administrator confirmed that testing should occur upon installation, but the facility lacked documentation of actual installation dates.
A resident, who required two-person assistance for bed mobility, fell out of bed when a CNA attempted to assist her alone, contrary to her care plan. The resident became wedged between the bed and the wall, highlighting the facility's failure to ensure staff were trained and aware of care plans. The Nursing Home Administrator was unaware of the frequent single-staff assistance, and several staff members had not received necessary education or competency testing.
A resident with quadriplegia was burned by hot coffee served at 185°F in bed, as the facility lacked safety protocols for hot liquids. The resident attempted to switch the coffee cup from his left to his weaker right hand, resulting in a spill and burns. The facility did not assess the safety of serving hot liquids to residents, nor did it monitor beverage temperatures, leading to this incident.
A resident receiving psychotropic and antipsychotic medications was not adequately monitored for behavior and side effects, leading to unnecessary medication use. The facility failed to document quantitative behavior tracking, using inappropriate charting methods. Staff interviews indicated the resident's behaviors were not harmful, contradicting the need for antipsychotic medication.
A resident with dysphagia and a history of aspiration events experienced two choking incidents due to inadequate supervision and failure to adhere to dietary restrictions. The resident was served inappropriate food items, leading to hospitalization. Staff interviews revealed a lack of clarity and responsibility in verifying meal tickets and ensuring correct diets, contributing to the deficiency.
The facility did not conduct annual performance reviews for three CNAs, as required by its policy. The last evaluations for these CNAs were conducted in 2022, despite their long-term employment. The facility's leadership indicated that evaluations were conducted every three years, contrary to the policy's annual requirement.
A resident with Vitamin B Deficiency did not receive their prescribed Vitamin B Complex-C medication due to unavailability, and the facility failed to notify the physician as required by policy. Despite the ADON being informed of the medication error, the physician was not notified, leading to a deficiency identified by surveyors.
A resident with cognitive intactness and multiple medical conditions reported a grievance about a CNA leaving her unable to eat her meal. The charge nurse was informed and reported the incident to the DON, but the grievance was not followed up on or formally documented, violating the facility's grievance policy.
A facility failed to report an alleged verbal abuse incident involving a resident to the State Agency. The resident's daughter reported that a CNA yelled at her mother, but the NHA closed the grievance due to lack of additional information from the daughter. The NHA acknowledged that the incident should have been reported as verbal abuse.
The facility failed to thoroughly investigate abuse allegations involving two residents. One resident was neglected during the night shift, and the investigation lacked interviews with day shift staff and other residents. Another resident's verbal abuse allegation was inadequately investigated, with no follow-up for non-verbal residents. The facility's policy for timely and thorough investigations was not followed.
A resident at risk for pressure injuries developed an infected pressure injury on her left foot bunion due to the facility's failure to implement timely interventions and assess contributing factors such as footwear. Despite being cognitively intact and having a care plan noting skin integrity risks, the facility did not conduct daily diabetic foot checks or address the cause of the initial redness, leading to the injury's progression and infection.
A facility failed to provide daily diabetic foot care for a resident with Type 2 Diabetes Mellitus, as required by their policy. The resident lacked a physician order for daily foot checks, resulting in the task not appearing on the TAR. Nursing staff only performed checks if listed on the TAR, and the DON confirmed checks were done weekly instead of daily, contrary to policy.
A resident with neurocognitive disorder and muscle weakness, who required 1:1 supervision due to wandering, was left unattended by a CNA, resulting in a fall. The resident's care plan lacked details on the required supervision, and the CNA acknowledged leaving the resident without ensuring a replacement. The RN and DON confirmed the need for continuous supervision, indicating a lapse in maintaining safety protocols.
A resident with Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness did not receive their prescribed Vitamin B Complex-C Oral Capsule due to a failure in the facility's pharmaceutical services. Despite multiple attempts by staff to resolve the issue with the pharmacy, the medication was unavailable for several weeks, indicating a breakdown in communication and procedure.
The facility failed to establish an effective infection prevention and control program, affecting all 106 residents. Issues included incomplete daily infection control surveillance for staff, inaccurate infection control line lists, and improper calculation of infection control rates. Additionally, a CNA did not disinfect a resident's bedside table after placing a urinal on it, posing a risk of cross-contamination.
The facility failed to complete PASARR Level II screens for four residents with serious mental illnesses or intellectual disabilities who stayed longer than 30 days, despite initial exemptions. This oversight was due to a change in responsibility for completing assessments and a gap in social worker staffing.
The facility failed to provide an ongoing program of activities to meet the interests and well-being of residents, particularly on weekends and evenings. Seven residents voiced concerns about the lack of activities, especially missing church services on Sundays. The activity staff and Nursing Home Administrator acknowledged the issue but had not implemented changes to address the deficiency.
The facility failed to ensure proper storage and labeling of medications, with surveyors observing undated, open stock medications, improperly stored refrigerated medications, and co-mingled administration routes in medication carts. Additionally, some medications were found without labels or resident identification, and expired medications were not discarded as per manufacturer recommendations.
The facility failed to follow its antibiotic stewardship program, leading to inappropriate and prolonged antibiotic use for several residents. Staff did not always document or clarify the necessity and duration of antibiotics, resulting in unnecessary treatments.
A resident with dementia, requiring moderate assistance for eating, was observed with a plate of food that remained in front of her for 34 minutes before a CNA began feeding her. The food temperature was found to be 113 degrees Fahrenheit, and the facility staff replaced the food.
The facility failed to report alleged abuse and a missing narcotic pain patch to the appropriate authorities and did not suspend the staff member involved in the abuse allegation. The facility did not follow its own policies and procedures, compromising resident safety during investigations.
The facility failed to investigate a potential misappropriation of a narcotic pain patch for a resident with moderate cognitive impairment. Despite facility policy requiring immediate reporting and thorough investigation of such incidents, no investigation was initiated when the patch was found missing. Interviews confirmed the oversight, and the NHA acknowledged the concern.
The facility failed to complete a discharge MDS assessment for a resident who passed away, despite policy requirements and confirmation from the Director of Nursing that the assessment was missing. The resident had Alzheimer's disease and was receiving end-of-life care.
The facility failed to ensure accurate MDS coding for a resident's CPAP usage. The resident's MDS incorrectly marked 'NO' for CPAP usage despite physician orders indicating its use. The MDS Coordinator confirmed the error, and the Nursing Home Administrator acknowledged the expectation for accurate MDS assessments.
The facility failed to ensure weekly wound measurements for a resident with a left stump wound, despite the facility's policy and professional standards of practice. Only 3 out of 12 required measurements were documented, as confirmed by the wound nurse and DON.
A resident with Schizophrenia missed two doses of the antipsychotic medication Pimozide due to unavailability. The facility's protocol for handling medication unavailability was not fully adhered to, resulting in the missed doses. Staff interviews confirmed that the pharmacy was contacted, but the medication could not be delivered in time.
The facility failed to ensure proper documentation and administration of pneumococcal vaccinations for three residents. One resident had a signed consent form without evidence of administration, while two others had no documentation of consent, declination, or administration. The LPN/IP confirmed the lack of follow-up and documentation, indicating a failure to adhere to the facility's immunization policies.
The facility failed to ensure accurate and accessible nurse staffing postings, with multiple discrepancies between the Daily Staff Roster and the Daily Census/Staffing document. The postings were placed high on a wall with small text, making them difficult to read, and residents confirmed they could not read them.
The facility failed to provide pharmaceutical services to meet the needs of six residents, resulting in multiple instances where medications were not administered as ordered. Residents missed doses of critical medications due to unavailability and lack of proper documentation or follow-up.
The facility failed to provide a support person for a resident with multiple medical conditions, leading to the cancellation of her necessary medical appointments and causing significant distress. The facility's policy required family or friends to accompany residents, despite the resident's APOAHC living out of the country and being unable to provide support.
The facility failed to document, investigate, and resolve a grievance expressed by a resident's APOAHC regarding the treatment by a CNA. The grievance was not recorded in the facility's log, and no investigation details were found. The NHA confirmed that the grievance should have been documented and investigated thoroughly.
A facility failed to update a resident's care plan to include the need for a support person during external appointments. Despite being cognitively intact and having multiple diagnoses, the resident's care plan was not revised, leading to distress during an attempted appointment. The Nursing Home Administrator confirmed the oversight during a survey.
The facility failed to ensure proper incontinence care for three residents, who were found to be using double incontinence briefs or additional products without proper care planning. Despite the facility's policy against double briefing, staff and residents confirmed its use due to heavy wetting.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Implement Fall Interventions and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that fall interventions were implemented according to the care plan and that residents received adequate supervision to prevent accidents, as evidenced by the experiences of three residents reviewed for falls and supervision. One resident, who was identified as a fall risk and had a history of 23 falls since admission, experienced repeated falls in similar locations and times, including a fall resulting in a head injury that required sutures. Despite the facility conducting a root cause analysis and collecting data on these incidents, there was no evidence that the interdisciplinary team comprehensively reviewed the data or considered increasing supervision for this resident. The care plan included multiple interventions, such as moving the resident closer to the nurse's station and providing increased monitoring, but these were not consistently or effectively implemented, particularly in the dining room where several falls occurred without increased supervision. Another resident, who was care planned to walk with a walker and have a sign in her room as a reminder, was observed on two separate occasions walking without her walker. Additionally, the required sign was not present in her room, indicating a failure to implement care plan interventions designed to reduce fall risk. This lack of adherence to the care plan placed the resident at increased risk for falls. A third resident, known to have wandering behaviors and a history of acting out toward staff and other residents, was not provided with increased supervision to prevent entry into other residents' rooms. This lack of supervision created a risk for potential resident-to-resident altercations. The facility's fall prevention policy required individualized assessment and implementation of interventions based on risk, but the observed failures in supervision and care plan implementation for these residents demonstrate noncompliance with the policy and regulatory requirements.
Failure to Follow Food Service Safety Standards During Meal Preparation
Penalty
Summary
Staff failed to follow professional standards for food service safety during meal preparation and service. During observation, a dietary aide was seen taking food temperatures at the steam table but did not allow the thermometer to dry after cleaning it with an alcohol wipe before placing it into the next food item. This practice was repeated for all foods being checked. Additionally, the dietary aide did not take the temperature of all food items, specifically omitting ground and pureed foods on the steam table. When questioned, the dietary aide stated that only certain foods deemed important were being checked for temperature. The facility's policy requires that temperatures for each food product and milk be measured and recorded at all meals, and that thermometers used for this purpose must be clean, sanitized, and dry before use. The dietary manager confirmed that all food temperatures should be taken at every meal and that the thermometer should be dry before being used in another food item. These observations and staff interviews demonstrate that the facility did not consistently store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all residents.
Failure to Prevent Resident Intrusions Violates Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not preventing a resident with dementia from repeatedly entering other residents' rooms uninvited. Multiple residents, including those who were cognitively intact and those with varying levels of cognitive impairment, reported that this resident would enter their rooms, sit on their beds or in their wheelchairs, and in one case, sat on a resident's recently operated knee, causing pain and distress. Staff and residents confirmed that these intrusions were ongoing and that the affected residents did not want this behavior to continue. Observations and interviews revealed that staff were aware of the wandering behavior and its impact on other residents. Staff described redirecting the resident as the primary intervention, but acknowledged that these efforts were not always effective. Some staff reported that the resident could become combative when redirected and that interventions such as walking with the resident, offering activities, or using visual cues like STOP signs had limited or no success. Documentation showed that the resident continued to wander into rooms, including at night, and that staff sometimes had to take turns sitting with her to prevent further incidents. Despite being aware of the problem and receiving grievances from residents, the facility did not implement effective interventions to prevent the resident from entering others' rooms uninvited. The affected residents expressed discomfort, frustration, and, in one case, physical pain as a result of these intrusions. The facility's actions and inactions led to a failure to honor residents' rights to dignity, privacy, and self-determination as required by policy and regulation.
Expired and Unlabeled Medications Found on Medication Cart
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were properly labeled and stored according to professional standards on one of three medication carts reviewed. During observation, several medications were found to be expired, including PRN Hydralazine, Chest Congestion Relief, ondansetron, stimulant laxative, and calcium antacid cards. Additionally, a nasal spray lacked an open date, and eye drops had an open date but were not properly monitored for expiration. These findings were confirmed during interviews with an LPN, who acknowledged that medications should be checked for expiration before administration and that expired medications should be discarded. The Director of Nursing stated that the process for removing expired medications involves the consultant pharmacist auditing the carts and medication rooms, with expired items being sent back to the pharmacy. However, the DON indicated uncertainty about the frequency of these checks, believing it to be monthly and requiring advance scheduling. The facility's own policy requires routine inspection for discontinued, defective, or deteriorated medications, but the observed deficiencies indicate this process was not consistently followed.
Failure to Assess Appropriateness for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications, as required by policy. A resident with diagnoses including polyosteoarthritis, type 2 diabetes mellitus, muscle weakness, and unspecified macular degeneration was observed with a cup of medications left on her bedside table for independent administration. There was no completed assessment or physician order in place at the time of the observation to support that the resident was safe to self-administer medications. The facility's policy requires an interdisciplinary assessment of the resident's physical and cognitive abilities, as well as a physician order, before allowing self-administration of medications. Record review showed that the resident had a BIMS score indicating cognitive intactness but required substantial to maximal assistance with activities of daily living and had limited range of motion in both upper extremities. The assessment tool used by the facility indicated that the resident could not name her medications, dosages, or reasons for use, and the assessment and order for self-administration were only completed after the surveyor's observation. Interviews with staff revealed that medications were left at the bedside based on the resident's preference to have them available before breakfast, but staff acknowledged that the resident did not meet all criteria for self-administration and that the required assessment process had not been followed prior to the incident. Further interviews with the resident and staff confirmed that the resident had recently needed help with medications and did not refuse to eat breakfast unless medications were present, contrary to staff assumptions. The staff responsible for completing the assessment had not directly discussed the process or the resident's preferences with her, and there was confusion among staff about the criteria required for self-administration. The deficiency was identified due to the lack of a completed assessment and physician order prior to allowing the resident to self-administer medications.
Failure to Investigate and Resolve Resident Grievance Regarding Staff Cell Phone Use
Penalty
Summary
The facility failed to document a thorough investigation and did not resolve a grievance as required by its own policy for one of four residents reviewed for grievances. A resident expressed concern during a Resident Council meeting about staff using personal cell phones while working. The concern was not entered into the facility's grievance log, and there was no documentation of an investigation or resolution. The Activities Director recalled the concern being brought to the previous Director of Nursing but was unsure if any follow-up occurred. The resident confirmed that no one had followed up with her regarding her concern, which remained unresolved at the time of the survey. Surveyors directly observed multiple staff members, including LPNs, using personal cell phones during work hours for non-work-related activities, such as opening a bank account, making a Facetime call, and discussing a resident. The Director of Nursing stated that there was no specific grievance documented regarding cell phones, although staff had reviewed cell phone expectations previously. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving, tracking, investigating, and resolving grievances, as well as notifying the complainant of the outcome. These steps were not followed in this case.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A deficiency occurred when a resident with dementia, seizure disorder, psychotic and mood disturbances, and moderate cognitive impairment was placed in a Broda chair with the brakes engaged while seated at the dining table. The brakes, located on the back lower wheels of the chair, were not accessible to the resident, preventing her from moving the chair independently. Multiple observations by the surveyor confirmed that the resident remained in this position for an extended period, attempting unsuccessfully to move the chair by grabbing the wheels, but was unable to do so due to the locked brakes. Interviews with facility staff revealed inconsistent understanding regarding the resident's ability to self-propel in the Broda chair and whether locking the brakes constituted a restraint. The facility's own policy defines a physical restraint as any device that restricts freedom of movement and cannot be easily removed by the resident. Despite this, the resident was repeatedly observed with the brakes engaged, restricting her movement, and staff acknowledged that this could be considered a restraint. The care plan indicated the resident required assistance with mobility and had a history of falls, but did not specify the use of restraints for medical treatment.
Failure to Develop and Implement Person-Centered Care Plans Addressing Communication and Religious Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the individual needs, preferences, and cultural requirements of three residents. For one resident with Alzheimer's disease and polyosteoarthritis, the care plan included the use of interpreter services to communicate in her preferred language, Nepalese. However, interviews with staff revealed that they were unaware of the resident's language, had not used interpreter services, and instead relied on gestures or attempts to use translation apps, which were unsuccessful. The care plan's instructions for using interpreter services were not followed, resulting in ineffective communication with the resident. Two other residents, both practicing Muslims, did not have their religious preferences or needs reflected in their care plans. One resident expressed distress about being unable to pray as required by her faith due to cleanliness requirements and the lack of a clean space. The other resident reported being denied access to the chapel for prayer and felt that staff did not consider individual religious needs. Despite both residents voicing these concerns, their care plans did not include any focus, goals, or interventions related to their religious practices or preferences. Facility policy requires that care plans be person-centered, culturally competent, and include measurable objectives and timeframes to meet each resident's medical, mental, and psychosocial needs. The policy also specifies that the care plan should identify the resident's language and communication tools if the resident is non-English speaking, and should incorporate cultural and religious preferences. The failure to include and implement these elements in the care plans for the three residents led to the cited deficiencies.
Failure to Update Discharge Plan to Reflect Resident's Goals
Penalty
Summary
The facility failed to develop a discharge plan that reflected a resident's goals and needs for one resident reviewed for discharge planning. The resident, who had diagnoses including depression, diverticulitis, and obstructive and reflux uropathy, was assessed as having moderate cognitive impairment. The resident's care plan indicated a long-term stay with the goal of remaining in the nursing home, despite the resident expressing a desire to move to assisted living. The care plan interventions included discussing feelings and goals for placement as needed, involving social services, and arranging for discharge if needed, but did not actively reflect the resident's stated goal of transitioning to assisted living. Interviews revealed that the resident had communicated his wish to move to assisted living to the social worker, who became aware of this goal in mid-January after being contacted by an assisted living facility. The social worker acknowledged working with the resident and his representative on enrolling in a managed care organization to facilitate placement. However, the care plan was not updated to reflect the resident's current discharge goal, despite both the social worker and the director of nursing agreeing that the care plan should have been revised as soon as staff became aware of the change in the resident's goals.
Failure to Honor Residents' Religious Preferences and Choices
Penalty
Summary
The facility failed to ensure that two residents, both practicing Muslims, received care and services in accordance with their comprehensive assessments and care plans, specifically regarding their religious and cultural needs. Both residents expressed that their religious practices, such as praying seven times a day and maintaining cleanliness before prayer, were not accommodated. The care plans for these residents did not reflect their religious preferences or primary language, despite these being significant to their well-being. Progress notes and interviews revealed that one resident was unable to pray as required due to not being provided with adequate opportunities for cleanliness, such as daily showers, and a clean space for prayer. The resident also reported not being offered individualized activities or support for her religious practices, and staff were either unaware of her religious needs or had incorrect information about her faith. The second resident, also a practicing Muslim, reported that he was not allowed to use the chapel for prayer and felt that his individual religious needs were not considered by the facility. Staff interviews indicated a lack of awareness regarding the resident's religious preferences, with some staff only noting dietary restrictions such as not eating pork. The activity director and director of nursing both acknowledged that religious preferences should be included in care plans if residents voice such concerns, but these were not documented or addressed in the care plans for either resident. Facility policies required that care and services be provided in accordance with residents' choices, values, and beliefs, and that care plans reflect these preferences. However, the facility did not follow its own policies, as evidenced by the lack of documentation and accommodation of the residents' religious needs. The deficiency was identified through interviews, record reviews, and observations, which consistently showed that the residents' spiritual and cultural needs were not being met as required.
Failure to Provide Timely ADL Assistance and Maintain Resident Dignity
Penalty
Summary
Two residents with significant care needs did not receive appropriate assistance with activities of daily living (ADLs), specifically in the areas of personal hygiene, grooming, and toileting, as required by their care plans. One resident, who was totally dependent on staff for personal hygiene and oral care due to multiple diagnoses including a femur fracture, failure to thrive, prostate cancer, anxiety disorder, and heart failure, was observed in the dining room in pajamas with unkempt hair and long, scraggly whiskers. Documentation for this resident's bathing, grooming, and hygiene was either missing or marked as not applicable for multiple consecutive days, and only the night shift was documenting these cares. The resident expressed dissatisfaction with his appearance and reported needing assistance with shaving and grooming, which was confirmed by staff interviews indicating a lack of clear guidelines on the frequency of shaving and grooming tasks. Another resident, with diagnoses including Parkinson's Disease, neuromuscular bladder dysfunction, muscle weakness, and cognitive impairment, was observed multiple times in soiled clothing and with a strong odor of urine. This resident required two-person assistance with transfers and toileting, as documented in the care plan, and was to be changed every two hours. However, staff interviews revealed that the resident was often left in wet briefs and clothing for extended periods, with some staff admitting that changes were not performed as scheduled, sometimes due to the resident's combative behavior. Documentation of care refusals was inconsistent, with only one refusal recorded in the relevant period, despite staff claims of frequent refusals. Observations and interviews confirmed that both residents did not receive the necessary services to maintain good hygiene, grooming, and dignity as outlined in facility policy and their individualized care plans. Staff failed to provide timely and adequate assistance with toileting and personal care, resulting in one resident being left in urine-soaked clothing and another with unaddressed grooming needs. These failures were corroborated by direct observations, resident interviews, and staff admissions, demonstrating a lack of adherence to established care protocols and policies.
Failure to Follow Physician Orders for Pressure Injury Care
Penalty
Summary
A resident with a stage 4 pressure injury on the left hip did not receive necessary treatment and services consistent with professional standards of practice to promote healing. Physician orders specified that the resident should not be in her wheelchair for more than one hour at a time, must be repositioned every 30 minutes while in the wheelchair, and should not lay on her left hip while in bed. These orders were not incorporated into the resident's care plan or care card, and staff were not consistently aware of or following these specific instructions. Observations by the surveyor revealed that the resident remained in her wheelchair for over an hour without being repositioned, despite verbalizing discomfort. Multiple staff interviews demonstrated inconsistent knowledge of the resident's repositioning requirements, with staff referencing standard protocols or the care card, which did not reflect the individualized physician orders. Staff responses varied, with some stating repositioning should occur every two hours, others indicating twice per shift, and some unaware of the specific restrictions regarding the resident's left hip. The Director of Nursing confirmed that physician orders should be followed as written but was not aware of the specific requirements for this resident. The care plan and care card lacked updates to reflect the physician's orders, and no new interventions were added after a wound infection. The facility was unable to provide a policy regarding pressure injury care when requested by the surveyor. As a result, the resident did not receive care in accordance with physician orders and professional standards, leading to a deficiency finding.
Failure to Provide Adequate Pain Management and Transfer Alternatives
Penalty
Summary
A resident with a history of chronic pain, including diagnoses such as Type 2 Diabetes Mellitus, hemiplegia, osteoarthritis, and rotator cuff pathology, experienced ongoing pain exacerbated by the use of an EZ stand lift for transfers. Despite being cognitively intact and repeatedly expressing that the EZ stand caused significant shoulder pain, the facility did not adequately address her pain needs or seek alternative transfer methods. The resident reported crying multiple times daily during transfers and requested re-evaluation for different transfer options, but received no response from therapy or facility leadership. Facility staff, including CNAs and the social worker, were aware of the resident's pain during transfers, with multiple staff members acknowledging that the EZ stand caused her distress and that she cried during each use. The care plan included interventions to evaluate pain management and check comfort levels, but there was no evidence that the plan was updated or that new interventions were implemented in response to the resident's ongoing complaints. The Director of Nursing and other staff confirmed knowledge of the pain but did not initiate increased pain assessments, care plan revisions, or interdisciplinary team meetings as outlined in facility policy. Medication records showed frequent use of both scheduled and PRN pain medications, and physician notes documented persistent pain despite these interventions. The facility failed to reassess the resident's pain management plan or develop and implement new approaches to transferring, and did not ensure that front line staff were informed of the resident's preferences regarding transfers. As a result, the resident continued to experience daily pain associated with the use of the EZ stand, and her care plan was not revised to address her ongoing needs.
Failure to Assess and Supervise Resident's Use of Lift Chair Resulting in Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for one resident. The resident, who had a history of falls, osteoporosis, depression, and dementia, required substantial to maximum assistance with most activities of daily living and was assessed as cognitively intact. Despite these needs, the facility did not adequately assess or monitor the resident's ability to safely use a lift chair, which was a known risk factor for falls. The resident was first observed sliding out of a recliner, prompting a recommendation from therapy to use non-slip matting. However, after a subsequent fall from the lift chair, the intervention was to unplug the chair due to the resident's lack of safety awareness. The care plan was updated accordingly, but the chair was later plugged back in without documented evidence of a reassessment of the resident's ability to use it safely. This lack of documentation and assessment persisted even after the resident experienced another fall from the lift chair, resulting in a femur fracture. Interviews with facility staff revealed that there was no specific fall prevention education provided to staff during orientation or in the previous six months. Additionally, the facility was unable to provide documentation of discussions or assessments regarding the decision to allow the resident to use the lift chair again. The absence of a thorough assessment and lack of staff education contributed to the resident's repeated falls and injury.
Failure to Follow Prescribed Diet Texture for Resident
Penalty
Summary
The facility failed to follow the prescribed easy to chew (Level 7) diet for a resident with multiple diagnoses, including Parkinson's disease, generalized muscle weakness, reduced mobility, adult failure to thrive, and dysphagia. The resident's care plan and physician orders specified a Level 7: Easy to Chew diet, which is intended for individuals who have difficulty chewing and/or swallowing regular textured foods. Despite these orders, the resident was observed with snacks such as cheese crackers, Cheetos, and potato chips in her room, which are not compliant with the prescribed diet. Interviews with staff revealed that both certified nursing assistants and the speech therapist allowed the resident to have snacks outside of her diet restrictions, citing quality of life and the resident's preferences. The speech therapist acknowledged making exceptions for the resident but did not document these exceptions or communicate them to the interdisciplinary team. The registered dietician confirmed that these snacks were not in compliance with the Level 7 diet and that any quality of life exceptions should have been documented in the care plan, which had not occurred. Further interviews with the resident and her family confirmed that she regularly received and consumed snacks not aligned with her prescribed diet, provided both by staff and family members. The director of nursing acknowledged that the speech therapist's exceptions were not documented and not included in the resident's care plan. There was no evidence of a risk and benefit analysis or an order in the medical record to support deviations from the prescribed diet.
Conflicting Care Plan Entries on Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident, resulting in conflicting information regarding the resident's ability to self-administer medication. The resident's care plan contained an undated notation stating that the resident may self-administer scheduled oral medications after set-up, while another intervention dated 05/02/24 indicated that the resident may not self-administer medications and must be observed taking them. Additionally, a focus item in the care plan initiated on 01/02/25 set a goal for the resident to be safe in self-administration of medications. However, review of the resident's orders in the electronic medical record did not reveal any order authorizing self-administration of medication. Interviews with staff revealed further confusion, as an LPN stated she was aware the resident could self-medicate based on a special order banner in the EMR, but was unaware of the conflicting care plan entries. The Director of Nursing acknowledged the presence of conflicting information in the care plan regarding the resident's self-medication status. The resident in question had a history of multiple diagnoses, including malignant neoplasm of the ileum, urinary tract infection, sepsis, acute respiratory failure, diabetes, depression, mild cognitive impairment, and insomnia, and was assessed as cognitively intact.
Failure to Ensure Proper Installation and Testing of Bed Rails
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for four residents, identified as R3, R6, R7, and R8. The deficiency was identified through observation, interviews, and record reviews, revealing that bed rails were installed without conducting a Bed System Measurement Device Test to ensure proper installation and reduce the risk of entrapment. The facility's policy requires that physical devices, including bed rails, be reviewed for safety and used according to the manufacturer's recommendations, with regular inspections to prevent safety hazards. For resident R3, the surveyor observed a gap between the bed rail and the mattress, indicating improper installation. The Maintenance Supervisor (MS C) admitted that a newly hired employee, who had not been trained on the measurement device, was installing bed rails. MS C also acknowledged that several installations had not been tested for entrapment points. The facility provided a Bed System Measurement Device Test for R3 dated after the surveyor's request, with no prior documentation of testing. Similarly, residents R6, R7, and R8 had bed rails installed without prior testing documentation. The facility's records indicated order dates for the bed rails, but no evidence of testing before the surveyor's intervention. The Nursing Home Administrator (NHA A) confirmed that testing should occur upon installation, but the facility lacked documentation of actual installation dates, relying instead on order dates. This oversight in testing and documentation led to the deficiency identified by the surveyors.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, leading to a fall incident. The resident, who was cognitively intact and required assistance from two staff members for bed mobility and transfers, fell out of bed when a CNA attempted to assist her alone. The resident's care plan and Kardex clearly stated the need for two-person assistance, but this was not followed, resulting in the resident sliding off the bed and becoming wedged between the bed and the wall. The incident occurred while the CNA was assisting the resident with toileting, and the resident's head was caught between the bed and the side rail, although she later clarified that her head was lower than the side rail. The facility's failure to ensure all staff were trained and aware of the resident's care plan contributed to the incident. The resident reported that staff frequently assisted her alone, despite the care plan's requirement for two-person assistance, and this practice continued even after the fall. The Nursing Home Administrator was unaware of the frequency of single-staff assistance and acknowledged that not all staff had been educated on following the Kardex. Additionally, several staff members, including the CNA involved in the incident, had not received the necessary education or competency testing as part of the facility's post-event action plan.
Resident Burned by Hot Coffee Due to Lack of Safety Protocols
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents, as evidenced by an incident involving a resident who sustained burns from hot coffee. The resident, who was cognitively intact but had physical impairments including quadriplegia, was served coffee in bed. The coffee was served at a temperature of 185 degrees Fahrenheit, which was not monitored or adjusted for safety. The resident attempted to switch the coffee cup from his left hand to his right hand, which was weaker, resulting in the coffee spilling and causing burns to his right flank and buttocks. The facility did not have a process in place for assessing the safety of serving hot liquids to residents, nor were there any specific care plans addressing the risks associated with hot liquids for this resident. The staff routinely provided the resident with coffee in his personal thermos cup without conducting any safety assessments or monitoring the temperature of the coffee. The incident report and interviews with staff revealed that there was no established protocol for ensuring the safe handling of hot beverages by residents, particularly those with physical impairments. Interviews with staff indicated a lack of awareness and training regarding the risks of serving hot liquids to residents. The facility's policy on food safety and preventing burns was not effectively implemented, as staff were not monitoring the temperatures of hot beverages at the point of service. The absence of a structured process for evaluating residents' ability to safely handle hot liquids contributed to the incident, highlighting a significant oversight in the facility's safety protocols.
Inadequate Monitoring and Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic and antipsychotic medications was free from unnecessary medications. The resident, who was admitted with diagnoses including Alzheimer's Disease and Generalized Anxiety Disorder, was prescribed Seroquel and Lorazepam without an appropriate diagnosis for antipsychotic medication. The facility's policy requires that antipsychotic drugs should not be used unless the resident's medical record clearly indicates specific conditions, which was not the case for this resident. The facility did not adequately track quantitative measurements during behavior tracking, which is necessary to measure the efficacy of medication therapy. The resident's Treatment Administration Record (TAR) showed numerous instances where behavior monitoring and side effect monitoring were not properly documented. Instead of recording the number of episodes or using 'Y' or 'N' to indicate behaviors and side effects, staff frequently used 'X' or check marks, which are not appropriate according to the facility's Director of Nursing. Interviews with staff, including RNs, CNAs, and the DON, revealed that the resident's behaviors were not persistent or harmful to themselves or others, contradicting the need for antipsychotic medication. The staff indicated that the resident could be verbally aggressive but was easily redirected and not physically aggressive. The lack of proper documentation and monitoring of the resident's behaviors and medication side effects contributed to the deficiency identified by the surveyors.
Inadequate Supervision and Dietary Compliance Leads to Choking Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to dietary restrictions for a resident with a history of dysphagia and aspiration events. The resident, who has diagnoses including Parkinson's Disease, dementia, and chronic dysphagia, experienced two choking incidents within a month. On the first occasion, the resident choked on a hot dog, requiring the Heimlich maneuver and hospitalization for acute hypoxic respiratory failure and aspiration pneumonitis. Despite this incident, the facility did not adequately supervise the resident's meals, leading to a second choking event. During the second incident, the resident was served a bowl of honeydew melon, which was not consistent with the prescribed Level 6 soft and bite-sized diet. This resulted in another aspiration event and subsequent hospitalization. Interviews with staff revealed a lack of clarity and responsibility regarding the verification of meal tickets and the appropriateness of food served. The CNA and dietary staff were both identified as responsible for ensuring the correct diet was served, yet the resident received inappropriate food items, leading to the choking incident. The facility's care plan and dietary restrictions for the resident were not followed, contributing to the immediate jeopardy situation. The resident's care plan indicated a need for supervision during meals and specific dietary restrictions, which were not adhered to. Staff interviews highlighted issues with communication and training regarding diet textures and meal ticket verification, which were factors in the deficient practice.
Removal Plan
- The facility will complete mock drills and competency tests for all licensed nursing staff including how to support a resident with partial obstructed airway, choking, Heimlich etc.
- The facility will educate nursing, culinary and activities staff on altered diets/IDDSI. The training will include how to determine foods/fluids safe to consume on prescribed/altered diets. A competency will be completed following education.
- The facility will provide instruction to culinary, activities and nursing staff on where to find a resident's diet.
- The facility has created a system where all meal tray cards for residents on an altered diet will be printed in a different orientation format, so it will be easily recognizable to staff to determine the appropriate diet and food/fluids safe to consume per the prescribed diet.
- The facility will ensure that a licensed nurse is assigned to each dining room.
- The facility will audit all resident diet orders, tray cards, care plan and Kardex to ensure correct orders and that orders match and include ST recommendations for residents who have been on ST caseload.
- The facility will complete meal audits to ensure receiving proper diet breakfast, lunch, and dinner in 2 dining rooms each meal.
- The facility will audit all employee records for licensed nurses to ensure CPR certification. The facility will ensure a licensed nurse is assigned to each dining room during all meals.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) had documented performance reviews conducted annually, as required by the facility's policy. The policy, titled Competency Assessment and Validation, mandates that competency should be assessed annually to ensure all employees are competent in their assigned responsibilities. However, the surveyor's review of the CNA performance review documentation revealed that the last evaluations for CNAs J, K, and L were conducted in 2022, despite their employment at the facility for over a year. Specifically, CNA J was last reviewed on April 18, 2022, CNA K on April 24, 2022, and CNA L on February 27, 2022. During an interview with the facility's new Nursing Home Administrator (NHA M), Chief Executive Officer (CEO N), and Regional Director (RD O), it was indicated that the facility's practice was to conduct CNA evaluations every three years, contrary to the annual requirement stated in the policy. The facility provided the most recent evaluations from 2022 but could not provide any additional documentation to support compliance with the annual review requirement. This discrepancy between the facility's policy and practice led to the deficiency identified by the surveyor.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, specifically for a resident who was not administered a prescribed medication. The resident, who was admitted with diagnoses including Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness, had an order for Vitamin B Complex-C Oral Capsule to be taken daily. However, the medication was not available from 6/13/24 onwards, and the facility did not notify the resident's physician about this issue. The facility's policy requires immediate notification of the physician in cases of significant treatment alterations, but this was not adhered to. The Assistant Director of Nursing (ADON) was informed of the medication error but did not notify the physician. The Director of Nursing (DON) expected the physician to be informed and the medication to be obtained within 48 hours, which did not occur. The failure to notify the physician and obtain the medication as per the facility's policy led to the deficiency identified by the surveyors.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of a grievance reported by a resident, identified as R8, who is cognitively intact with a BIMS score of 15 and has medical conditions including diabetes, heart failure, and reduced mobility. R8 reported an incident where an agency CNA left her room without setting up her meal, leaving her unable to eat. R8 expressed feelings of sadness and vulnerability due to the incident. The charge nurse, RN C, was informed of the situation and reported it to the Director of Nursing (DON B) via text message. However, the grievance was not followed up on by DON B, and it was not filed as a formal grievance as required by the facility's policy. The incident occurred during dinner time when CNA E left R8's room to retrieve a clothing protector, and R8 allegedly called CNA E a derogatory name. CNA D intervened, assisted R8 with her meal setup, and reported the incident to RN C. Despite these actions, the facility's grievance policy, which mandates prompt resolution and communication with the resident, was not adhered to, as DON B did not take further action to address the grievance. This lack of follow-up and formal documentation of the grievance constitutes a deficiency in the facility's grievance handling process.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a resident to the State Agency as required by state and federal regulations. The incident involved a resident whose daughter emailed the Nursing Home Administrator (NHA) alleging that a Certified Nursing Assistant (CNA) was yelling at her mother. According to the facility's Abuse, Neglect, and Exploitation Policy and Procedure, such allegations must be reported immediately to the administrator and the State Agency within two hours of forming the suspicion. However, the facility did not adhere to this policy. The grievance was documented in the facility's Grievance Log, indicating that the NHA reached out to the resident's daughter for more details about the incident, such as the date, time, and witnesses. The daughter did not respond to the NHA's request for additional information, leading the NHA to close the grievance due to a lack of information. During an interview with a surveyor, the NHA acknowledged that the allegation of yelling constituted verbal abuse and should have been reported, but it was not.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving two residents. For one resident, an allegation of neglect was reported, indicating that care was not provided during the night shift, resulting in the resident being found soaked with urine. The investigation was incomplete as it did not include interviews with day shift staff or other residents, and there was no documentation of investigative procedures for non-interviewable residents. The Director of Nursing acknowledged that a thorough investigation was not conducted. In another case, a grievance was filed by a resident's daughter, alleging verbal abuse by a CNA. The Nursing Home Administrator initially closed the grievance due to a lack of response from the complainant. However, upon further review, it was found that some investigation had been conducted, including staff interviews and an interview with the resident. Despite this, there was no follow-up with other residents who might not be able to voice their concerns, and the grievance log was not updated to reflect the investigation. The facility's policy requires timely and thorough investigations of all abuse allegations, but these incidents demonstrate a failure to adhere to these procedures. The lack of comprehensive investigations and documentation highlights deficiencies in the facility's response to abuse allegations, as confirmed by interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Prevent and Manage Pressure Injury in Resident
Penalty
Summary
The facility failed to implement professional standards of practice to prevent and manage pressure injuries for a resident identified as R3, who was at risk for pressure injuries due to her medical conditions, including Type 2 Diabetes Mellitus. Despite being cognitively intact and having a Braden Scale score indicating risk, the facility did not include daily diabetic foot checks in R3's physician orders. The care plan for R3 noted the risk for skin integrity issues but did not adequately address the specific needs related to her condition. R3 developed a pressure injury on her left foot bunion, which was initially noted as a red, blanchable area. Over time, the condition worsened, leading to an open wound that became infected, necessitating the use of oral antibiotics. The facility's documentation showed that interventions were not promptly implemented when the reddened area was first observed. The facility also failed to assess the cause of the redness and did not evaluate R3's footwear, which was later identified as a contributing factor to the injury. Interviews with nursing staff and the Director of Nursing revealed that there was a lack of immediate intervention and assessment regarding R3's condition. The staff acknowledged that interventions should have been put in place earlier to prevent the development of the pressure injury. The facility's oversight in not conducting daily diabetic foot checks and not addressing the footwear issue contributed to the development and subsequent infection of the pressure injury on R3's bunion.
Failure to Provide Daily Diabetic Foot Care
Penalty
Summary
The facility failed to provide diabetic foot care in accordance with professional standards of practice for a resident with Type 2 Diabetes Mellitus. The facility's policy, revised in October 2022, mandates daily foot care for diabetic residents to maintain mobility and foot health. However, the resident in question did not have a physician order for daily diabetic foot checks, which resulted in the absence of this task on the Treatment Administration Record (TAR). Consequently, the nursing staff did not perform or document daily foot checks for the resident. Interviews with nursing staff revealed that diabetic foot checks were only completed if they appeared on the TAR, which requires a physician's order. The Director of Nursing (DON) acknowledged that foot checks were conducted weekly during routine skin checks on shower days, contrary to the facility's policy. The DON expressed skepticism about the feasibility of daily checks and was unable to provide an alternative policy to the surveyor.
Failure to Maintain 1:1 Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for a resident who was supposed to be under 1:1 supervision. The resident, who had been admitted with diagnoses including frontotemporal neurocognitive disorder and muscle weakness, had recently returned from a hospital stay and was noted to wander around the unit. Despite the need for close supervision, the resident's care plan did not include information about 1:1 supervision. On the day of the incident, a CNA assigned to supervise the resident left the resident unattended, resulting in the resident falling in the hallway. During the survey, the RN on duty confirmed that the resident was supposed to be under 1:1 supervision and that the CNA should not have left the resident alone. The CNA acknowledged that she should have stayed with the resident until someone else could take over. The Director of Nursing also confirmed that the resident was considered to be on 1:1 supervision and that staff should not leave such residents unattended. This lack of supervision led to the resident's fall, highlighting a failure in maintaining the required level of care and supervision for the resident's safety.
Failure to Provide Required Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R5, who had a physician's order for Vitamin B Complex-C Oral Capsule. The medication was not available for administration from 6/11/24 and from 6/13/24 through 6/27/24. R5 was admitted with diagnoses including Vitamin B Deficiency, Multiple Sclerosis, and Muscle Weakness, and had an order to receive the supplement daily. The facility's policy requires the provision of pharmaceutical services to ensure the accurate acquisition, receipt, dispensing, and administering of all drugs and biologicals. Interviews with facility staff revealed a breakdown in communication and procedure regarding the medication's availability. RN F reported the issue to the nurse manager and ADON G, indicating that the medication was not provided by the pharmacy as expected. ADON G confirmed a medication error report was completed and noted that the pharmacy claimed they did not have an order for the medication, despite previous orders. DON B indicated multiple attempts to communicate with the pharmacy to resolve the issue, but the medication was still not received. This deficiency highlights a failure in the facility's pharmaceutical service procedures, impacting the resident's care.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility has not established an effective infection prevention and control program, which has the potential to affect all 106 residents. The facility failed to ensure daily infection control surveillance for staff, resulting in incomplete infection control line lists for both staff and residents. Additionally, the facility's monthly infection control rates were not calculated according to current standards of practice, and the March 2024 COVID outbreak summary was found to be incomplete and inaccurate. During an interview, the LPN/IP indicated that the facility does not have documentation of daily surveillance for staff and was unsure when this was last completed. The staff call-in logs reviewed by surveyors were found to be incomplete, with many entries lacking symptomology. This lack of daily surveillance prevents the facility from ensuring correct exclusionary criteria, return-to-work dates, and the ability to prevent, identify, report, investigate, and control infections and communicable diseases. The infection control line lists for residents and staff were also found to be incomplete. For example, the Resident LTC Respiratory Surveillance Line List for January 2024 contained missing information such as the type of test ordered, pathogen detected, and symptom resolution. Similarly, the Staff LTC Respiratory Surveillance Line List for January and February 2024 lacked critical information such as the date last worked, type of test ordered, pathogen detected, and return-to-work dates. Additionally, the March 2024 COVID Outbreak Summary did not match the line list information, indicating that six staff members were not identified in the outbreak summary. Furthermore, an observation revealed that a CNA did not disinfect a resident's bedside table after placing a urinal on it, posing a risk of cross-contamination. The facility's infection prevention and control program was found to be lacking in several areas, including daily surveillance, accurate and complete line lists, and proper calculation of infection control rates. These deficiencies highlight the need for a more organized and effective infection control program to ensure the safety and well-being of residents and staff.
Failure to Complete PASARR Level II Screens
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II for residents who stayed longer than 30 days, despite initial exemptions. This deficiency affected four residents who had serious mental illnesses or intellectual disabilities and were on psychotropic medications. The facility's policy required a PASARR Level I screen for all new admissions and a Level II screen if the stay exceeded 30 days, but this was not adhered to for the residents in question. Resident R41, with diagnoses including Generalized Anxiety Disorder and Depression, and on Risperidone, did not have a PASARR Level II screen completed after exceeding the 30-day exemption. Similarly, Resident R89, with Major Depressive Disorder and Anxiety Disorder, and on Duloxetine, also lacked a PASARR Level II screen. Resident R36, with Major Depressive Disorder and on Lexapro, and Resident R103, with bipolar disorder and on multiple psychotropic medications, were also not screened as required. The Director of Nursing indicated a change in responsibility for completing PASARR assessments led to these oversights, and the Nursing Home Administrator acknowledged the deficiency, noting a gap in social worker staffing.
Lack of Adequate Activity Program for Residents
Penalty
Summary
The facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency affected seven residents who voiced concerns during the Resident Council about the lack of activities, particularly on weekends and evenings. The facility's policy, issued in February 2021, mandates that activities should be appropriate, stimulating, and promote the well-being of residents, considering their individual differences and interests. However, the facility's activity schedule showed limited activities on Saturdays and none on Sundays, failing to meet these requirements. Residents R41, R79, R24, R42, R53, R22, and R59 expressed dissatisfaction with the activity program, noting that there were only one-hour activities on Saturdays and no activities on Sundays. They specifically mentioned missing church services on Sundays, which they used to attend with their families. The activity staff, including the Activity Aide and Activity Director, confirmed the limited scheduling and acknowledged the residents' concerns. They mentioned efforts to find volunteers to lead weekend activities but had not succeeded yet. The Nursing Home Administrator was aware of the residents' complaints and agreed that the activity staff should offer more activities during evenings and weekends. Despite this awareness, no changes had been implemented to address the deficiency. The facility's current activity schedule and staffing did not support the residents' needs for more frequent and varied activities, particularly on weekends and evenings, leading to the deficiency noted by the surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with currently accepted professional practices. In one of the medication rooms and several medication carts, surveyors observed multiple instances of undated, open stock medications, medications that should have been refrigerated but were not, and medications with illegible expiration dates. Additionally, different medication administration routes were co-mingled in the same bag, and some medications were found without any labels or resident identification. In one instance, an open vial of Tuberculin purified protein was found without a documented open date, and the RN was unable to state how long the vial had been open. Similarly, a bottle of Florajen was found without an open date or a date indicating when it was removed from the refrigerator. Other examples included undated eye drops, nasal sprays without resident labels, and medications stored together that should have been separated according to their administration routes. Further observations revealed expired medications, such as Latanoprost eye drops and Fluticasone nasal spray, which were not discarded after the recommended period. Additionally, some medications requiring refrigeration, like Promethegan suppositories, were found in medication carts instead of being stored in the refrigerator. The Director of Nursing confirmed that these practices were not in line with the facility's medication storage policy and manufacturer recommendations.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility did not adhere to its antibiotic stewardship program, resulting in inappropriate antibiotic use for several residents. One resident continued an antibiotic for three days without an appropriate indication, and another was ordered and took an antibiotic without meeting the infection criteria. Additionally, a third resident was given an antibiotic before test results were returned and continued to take it despite the lack of appropriate indications for its use. A fourth resident received a prophylactic antibiotic for several months without a clear rationale or end date indicated. The facility's policy on infection prevention and control, which includes an antibiotic stewardship program, was not followed. The Licensed Practical Nurse/Infection Preventionist (LPN/IP) did not always document discussions with providers regarding the necessity of antibiotics, and in some cases, did not contact the provider at all. This led to residents receiving antibiotics without meeting the infection criteria or without proper documentation and rationale for their use. Interviews with staff revealed that there were lapses in following up on antibiotic orders and clarifying the duration of antibiotic use. The Director of Nursing (DON) and other staff members acknowledged that they did not always ensure that antibiotics were prescribed and continued based on appropriate indications and current standards of practice. This lack of adherence to the antibiotic stewardship program resulted in unnecessary and prolonged antibiotic use for the residents involved.
Resident Served Cold Food
Penalty
Summary
The facility did not ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature for one resident observed during dining. The resident, who has dementia and requires moderate assistance for eating, was observed sitting at a dining room table asleep in her wheelchair with a plate of food in front of her. The food remained in front of the resident for approximately 34 minutes before a CNA began feeding her. At that time, the surveyor requested the temperature of the lasagna, which was found to be 113 degrees Fahrenheit. The facility staff then replaced the resident's food.
Failure to Report Alleged Abuse and Missing Narcotics
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the administrator and other officials, and that residents were protected during the facility's investigation. In the case of one resident, the facility did not suspend the staff member named in the abuse allegation as required by the facility's Abuse Policy and Procedure. The Director of Nursing (DON) and Nursing Home Administrator (NHA) determined that the incident was a customer service issue rather than abuse, despite the complainant using the term 'abuse.' The staff member continued to work during the investigation, although not with the resident involved in the allegation. In another instance, the facility failed to report a missing narcotic pain patch for a resident. The nurse who discovered the missing patch reported it to the nurse manager on duty, but the information was not relayed to the DON or the administrator. The DON confirmed that such incidents should be reported up the chain of command and could be considered potential misappropriation or diversion. The facility did not report the missing narcotic patch to the state agency until the surveyors brought it to their attention. These deficiencies highlight the facility's failure to follow its own policies and procedures for handling allegations of abuse and missing narcotics. The lack of immediate reporting and appropriate protective measures for residents during investigations compromised the facility's ability to address and resolve these serious issues effectively.
Failure to Investigate Missing Narcotic Pain Patch
Penalty
Summary
The facility failed to investigate a potential misappropriation of a narcotic medication for a resident (R41) who was reviewed for abuse. On 4/17/24, the facility became aware of a potential misappropriation involving R41's narcotic pain patch, but this was not reported to the Nursing Home Administrator for an investigation to be completed. The facility's policy on Abuse, Neglect, and Exploitation, reviewed in November 2023, mandates that any suspected abuse, neglect, or exploitation be immediately reported to the administrator and thoroughly investigated. However, this procedure was not followed in the case of R41's missing Buprenorphine Transdermal Patch, a narcotic medication. R41, who was admitted to the facility with diagnoses including pain in the right knee, other congenital malformations, and unspecified convulsions, has a moderate cognitive impairment as indicated by a BIMS score of 10. On 4/17/24, a nurse's note documented that R41's patch was not present that morning. Despite this, no investigation was initiated. Interviews with the RN who authored the note and the DON confirmed that the missing patch should have been investigated as potential misappropriation or diversion but was not. The NHA acknowledged the concern during the exit conference, and it was noted that the facility did not complete an investigation into the missing patch, although they had submitted a report to the state agency regarding the incident.
Failure to Complete Discharge MDS Assessment for Deceased Resident
Penalty
Summary
The facility did not ensure comprehensive assessments were completed as required for one of the three closed records reviewed for Minimum Data Set (MDS) assessments. Specifically, the facility failed to complete a discharge MDS assessment for a resident (R12) who passed away. The facility's policy, which aligns with the Centers for Medicare and Medicaid Services' RAI Manual, mandates that a discharge MDS assessment be completed when a resident dies. However, upon review of R12's medical record, it was noted that no discharge MDS was completed upon the resident's passing. R12 was admitted to the facility with diagnoses including Alzheimer's disease and was receiving end-of-life care by the facility and a hospice agency. The resident's nurse notes indicated that a hospice RN formally pronounced the resident as deceased and contacted the family and funeral home. Despite this, the Director of Nursing (DON) confirmed that R12's medical record did not contain the required discharge MDS. The DON indicated that the facility contracts with an external company to complete MDS assessments and would need to contact them to rectify the omission.
Inaccurate MDS Coding for CPAP Usage
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status for one resident (R43) out of a total sample of 27. Specifically, R43's Minimum Data Set (MDS) dated [DATE] did not correctly code her Continuous Positive Airway Pressure (CPAP) usage. The facility does not have a specific Policy and Procedure for MDS accuracy and follows the Resident Assessment Instrument (RAI) manual. According to the RAI manual, the assessment must accurately reflect the resident's status. R43's physician orders indicated CPAP usage starting from 6/16/22, but the MDS incorrectly marked 'NO' for CPAP usage. Upon review, the MDS Coordinator confirmed the error and stated that a modification would be needed to correct it. The Nursing Home Administrator also confirmed that MDS assessments are expected to be completed accurately.
Failure to Document Weekly Wound Measurements
Penalty
Summary
The facility did not ensure treatment and care in accordance with professional standards of practice for a resident with a wound on the left stump. The resident, who is cognitively intact and has diagnoses including Acquired Absence of Left Leg, Peripheral Vascular Disease, and Multiple Sclerosis, did not have weekly measurements documented for the wound as required. The facility's policy on Pressure Ulcer/Skin Integrity mandates routine ongoing documentation of the resident's skin condition and response to care, but it does not specify detailed parameters for wound assessment. Despite this, both the wound nurse and the Director of Nursing (DON) acknowledged that weekly measurements should be conducted for any open wound. The surveyor's review of the Weekly Skin Check Tool and nursing progress notes revealed that from the time the wound was first noted on 2/8/24 until 5/2/24, there should have been 12 weekly wound measurements. However, only 3 measurements were documented. Interviews with the wound nurse and the DON confirmed the lack of weekly measurements, indicating a failure to adhere to the facility's policy and professional standards of practice. This deficiency was identified through observations, staff interviews, and record reviews conducted by the surveyors.
Significant Medication Error Due to Unavailability of Antipsychotic Medication
Penalty
Summary
The facility did not ensure that residents are free of significant medication errors, as evidenced by the case of a resident (R19) who missed two doses of an antipsychotic medication, Pimozide, in April. The resident, who has diagnoses including Schizophrenia, Major Depressive Disorder, and Insomnia, had a physician order for Pimozide 5mg to be taken once daily. The medication was not administered on two consecutive days, 4/28 and 4/29, due to it being unavailable. The facility's medication error log, Medication Administration Record (MAR), and Nursing Progress Notes confirmed the missed doses and documented the follow-up actions taken, including re-ordering the medication and notifying the nurse manager and provider. Interviews with facility staff, including a Registered Nurse (RN K), the Assistant Director of Nursing (ADON S), and the Director of Nursing (DON B), revealed that the medication was not available due to an insurance issue and that the facility's protocol for handling such situations was not fully adhered to. The staff indicated that the pharmacy was contacted, but the medication could not be delivered in time. The facility's policy requires that if a medication is not available, the pharmacy should be contacted immediately, and the provider should be notified if the medication is still unavailable after the first missed dose. The failure to follow these procedures resulted in the resident missing two doses of a vital medication.
Failure to Document and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation and administration of pneumococcal vaccinations for three residents. Resident R41 had a signed consent form for the Prevnar 20 vaccine, but there was no evidence of the vaccine being administered. During an interview, the LPN/Infection Preventionist (IP) confirmed that the immunization should have been given but could not locate any documentation of its administration. Resident R63's medical records lacked any documentation of pneumococcal vaccination, consent, or declination. The Wisconsin Immunization Registry (WIR) also did not contain any pneumococcal vaccination dates for R63, and the LPN/IP was unable to provide any additional information regarding the resident's vaccination status. Similarly, Resident R102's records did not contain documentation of consent or declination for pneumococcal vaccination. Although the WIR showed a previous administration of the Prevnar 13 vaccine, there was no follow-up documentation for the Pneumococcal 23 vaccine, and the LPN/IP admitted to not following up with the resident's Power of Attorney for consent. The facility's policy on pneumococcal immunizations states that all residents should be encouraged to obtain the vaccines unless contraindicated and that a system should be in place to offer these vaccines at the time of admission. The policy also requires that residents or their legal representatives receive education on the benefits and risks of the immunizations and that the medical record be updated to reflect the immunizations provided, education given, refusals, and any medical contraindications. The lack of documentation and follow-up in the cases of R41, R63, and R102 indicates a failure to adhere to these policies, resulting in incomplete records and potential gaps in resident care.
Inaccurate and Inaccessible Nurse Staffing Postings
Penalty
Summary
The facility did not ensure the nurse staffing posting was accurate and posted in an accessible area, potentially affecting the census of 106 residents. Multiple daily staff postings did not reflect the actual hours of the nursing staff. The postings were placed high on a wall with small text, making them difficult to read. Specific discrepancies were noted on several dates where the Daily Staff Roster did not match the Daily Census/Staffing document. For example, on 4/17/24, the roster did not reflect that an LPN was scheduled as the nurse manager for the day shift, and the night shift showed discrepancies in the number of LPNs scheduled. Similar inconsistencies were observed on 4/18/24, 4/19/24, and 4/27/24, where the number of CNAs and LPNs listed on the postings did not match the actual schedule. These inaccuracies were confirmed through interviews with the scheduler and residents, who also indicated that the postings were difficult to read due to their location and small text size. On 5/2/24, the surveyor interviewed the scheduler, who confirmed that the postings should reflect the actual schedule and be updated accordingly. The scheduler acknowledged the discrepancies and provided explanations for the mismatches, such as call-ins and errors in updating the postings. Residents interviewed also confirmed that they could not read the postings due to their height and small text. The scheduler admitted that the postings were created the day before and sent to the night nurse, with charge nurses responsible for updating them by 2 PM on the day of the posting. However, this process was not consistently followed, leading to the observed discrepancies and accessibility issues.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of six residents, resulting in multiple instances where medications were not administered as ordered. Specifically, residents R4, R7, R18, and R21 did not receive their medications as prescribed. For example, R4 did not receive Cefprozil for COVID-19 on one occasion, and R7 missed doses of Simethicone and Calcium Carbonate due to medication unavailability. R18 also missed a dose of Senna, with facility documentation indicating that the medication was not available. The Vice President of Clinical Services (VPCS) acknowledged that there was a misunderstanding during the transition from an in-house pharmacy to an outside pharmacy, leading to the unavailability of over-the-counter medications on specific dates. The Director of Nursing (DON) did not consider the undispensed medications to be a medication error and stated that the facility's channels to ensure timely medication administration failed on those dates. Resident R5, who has diagnoses including diastolic heart failure and chronic kidney disease, did not receive a scheduled dose of Lasix on one occasion. The Medication Administration Record (MAR) showed an empty box where the medication should have been signed out. R5's care plan indicated a focus on heart circulation and the need for medications, labs, and treatments as ordered. Similarly, R13, who has diagnoses including hypomagnesemia and insomnia, missed multiple doses of various medications, including Tylenol, Claritin, melatonin, trazodone, calcium, and magnesium. The MAR indicated that these medications were either not available or not administered, with no documentation in the nurse progress notes explaining why the medications were not given or what was done to attempt to administer them. Resident R21, diagnosed with bipolar disorder, also missed doses of critical medications. The MAR showed that lamotrigine and Seroquel were not administered on specific dates, with no indication in the nurse progress notes explaining the reasons or actions taken. The care plan for R21 included goals and interventions related to mood and behavior management, as well as psychotropic drug use, but the failure to administer the medications as ordered was not addressed. Interviews with the VPCS and DON revealed that the facility's process for handling unavailable medications was not followed, leading to these deficiencies in pharmaceutical services.
Failure to Provide Support Person for Resident's Medical Appointments
Penalty
Summary
The facility did not ensure that a resident (R1) was treated with dignity and respect by failing to provide a support person to assist her in attending medically necessary physician appointments. R1, who has multiple medical conditions including dementia, multiple sclerosis, and muscle weakness, was admitted to the facility with an Activated Power of Attorney for Health Care (APOAHC) who resides out of the country. Despite R1 being cognitively intact, the facility canceled her ophthalmology appointment because no support person was available to accompany her, leading to significant distress and agitation for R1. The facility's lack of a policy regarding appointments, transportation, and supervision contributed to this issue, as evidenced by the incident on 2/13/24 when R1 attempted to attend her appointment alone and became upset when redirected by staff. The facility's Nursing Home Administrator (NHA) communicated with R1's APOAHC, stating that the facility does not provide support persons for residents attending outside medical appointments and that it is the responsibility of the resident's family or friends. This policy was enforced despite R1's APOAHC living out of the country and being unable to provide a support person. The NHA also mentioned that the facility had been in communication with various parties, including R1's physician and managed care organization, who agreed that R1 needed a support person for safety reasons. However, the facility did not take responsibility for ensuring R1's safety during her appointments, leading to the deficiency. The surveyor's interview with the NHA revealed that the facility had previously sent staff to accompany R1 to appointments but decided to stop this practice, citing that it was not done for other residents. The NHA was unaware that it was the facility's responsibility to ensure R1's safety and honor her and her APOAHC's choice of physicians. The facility's failure to provide a support person for R1's medical appointments, despite her APOAHC's inability to do so, resulted in a deficiency in treating the resident with dignity and respect and ensuring her safety during necessary medical visits.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility did not make prompt efforts to resolve a grievance expressed by the Activated Power of Attorney for Healthcare (APOAHC) of a resident (R1). The APOAHC raised concerns to the previous Director of Nursing (DON) regarding the treatment of R1 by a Certified Nursing Assistant (CNA). However, the facility failed to document the grievance, investigate the allegations, or record any details about the incident. The facility's grievance log for the relevant period did not contain any entries related to R1's complaint, and no documentation of an investigation or statements was found. The Nursing Home Administrator (NHA) confirmed that the grievance should have been documented and investigated thoroughly, but no such records were available. R1, who was admitted with multiple diagnoses including dementia and multiple sclerosis, did not recall the concern when interviewed by the surveyor. The accused CNA is no longer employed at the facility, but the lack of documentation and investigation remains a significant issue. The facility's policy and procedure on the grievance process, revised in November 2022, stipulates that residents have the right to voice grievances without fear of reprisal and that the facility must make prompt efforts to resolve such grievances. The policy also requires the Executive Director to oversee the grievance process, including receiving, tracking, and investigating grievances, and maintaining records for three years. Despite these requirements, the facility did not adhere to its policy in handling the grievance related to R1, resulting in a deficiency noted by the surveyor.
Failure to Update Care Plan for Resident Requiring Support Person
Penalty
Summary
The facility did not ensure that care plans were reviewed and revised for a resident who required a support person while attending appointments outside the facility. The resident, who was admitted on 6/16/22 with diagnoses including dementia, multiple sclerosis, and muscle weakness, was found to be cognitively intact based on a Minimum Data Set (MDS) assessment. Despite being incapacitated since 8/6/21 and having an activated Power of Attorney for Health Care (APOAHC) who lives out of the country, the resident's care plan was not updated to reflect the need for a support person during external appointments. On 2/13/24, the resident attempted to leave the facility for an appointment and became upset when redirected by staff, demonstrating distress and agitation. The Nursing Home Administrator confirmed that the need for a support person was identified on 2/13/23, but the care plan was not updated accordingly. This oversight was identified during a survey, highlighting the facility's failure to revise the care plan to address the resident's needs adequately.
Failure to Provide Proper Incontinence Care
Penalty
Summary
The facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) received the necessary services for assistance with incontinence care. Specifically, three residents (R16, R23, and R24) were found to be using double incontinence briefs or additional incontinence products without proper care planning or adherence to facility policy. This practice was observed during interviews and care observations, where residents and staff confirmed the use of double briefs due to the residents being heavy wetters. However, the facility's Director of Nursing (DON) indicated that double briefing is not allowed and is not standard practice. Resident R16, who has diagnoses including hemiplegia, urinary incontinence, and a history of urinary tract infections, reported that she is double briefed almost every night. Similarly, Resident R23, who has functional and urge incontinence, was observed with a blue liner and pullup during morning care, and staff confirmed that double briefing occurs despite it not being care planned. Resident R24, who has urge incontinence and dementia, also reported requesting double briefs due to being a heavy wetter, and staff acknowledged that some comply with these requests even though it is against policy. Interviews with multiple CNAs revealed that double briefing is a common practice for residents who are heavy wetters, despite the lack of care planning and the facility's policy against it. The DON confirmed that staff should not use double briefs and that residents should be toileted more frequently if they are heavy wetters. The facility was unable to provide a policy on incontinence products, further highlighting the inconsistency in care practices and the lack of adherence to established protocols.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
