Complete Care At Ridgewood Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Racine, Wisconsin.
- Location
- 3205 Wood Rd, Racine, Wisconsin 53406
- CMS Provider Number
- 525608
- Inspections on file
- 31
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Complete Care At Ridgewood Llc during CMS and state inspections, most recent first.
A resident with chronic kidney disease and heart failure was not properly monitored for a physician-ordered 1500 ml fluid restriction, resulting in repeated overconsumption of fluids. Staff interviews revealed inconsistent and incomplete documentation and monitoring practices, with no comprehensive system to total fluid intake from all sources. The DON confirmed that these inconsistencies made it difficult to ensure compliance with the physician's order.
A resident with multiple chronic conditions and severe cognitive impairment had a Foley catheter re-inserted for urinary retention, but the care plan was not updated to reflect this change. Despite daily IDT meetings where care plans are reviewed for status changes, the oversight was not corrected, and staff acknowledged the care plan should have been revised.
Surveyors found expired stock medications, including Calcium with Vitamin D, Aspirin, and Iron, in a medication storage room. An RN unit manager acknowledged responsibility for checking for expired medications but was unsure of the frequency of checks. The DON confirmed that expired medications should not be left in medication rooms.
A resident with severe cognitive impairment and multiple medical conditions, who was fully dependent on staff for bathing, did not receive a scheduled shower for a two-week period as required by the care plan. Facility documentation and staff interviews confirmed the missed care, with no additional information provided regarding the lapse.
Two residents developed pressure injuries that were not comprehensively assessed or managed according to facility policy. One resident developed a deep tissue injury and a sacral ulcer without timely or complete wound assessments, and care plans were not individualized to address specific risk factors. Another resident's unstageable pressure injury was not fully assessed, with missing documentation of wound depth and bed, and the wound physician and RD were not promptly involved. These deficiencies reflect failures in assessment, documentation, and individualized care planning.
Two residents with cognitive and mobility impairments experienced multiple unwitnessed falls due to the facility's failure to conduct thorough root cause investigations and implement personalized fall prevention interventions. Generic measures such as ensuring call lights were within reach were inconsistently applied, and care plans were not updated to address specific risk factors like toileting needs, proper footwear, or visual impairments. Post-fall assessments lacked key details, and interventions such as fall mats and visual reminders were not tailored to individual needs or placed effectively, resulting in inadequate supervision and repeated accidents.
An LPN failed to perform hand hygiene at multiple critical points during wound care for a resident with complex medical needs, including after touching contaminated surfaces, changing gloves, and handling wound dressings. This was observed despite facility policy requiring hand hygiene before and after glove use and when moving between contaminated and clean tasks. The DON confirmed that proper hand hygiene was not maintained during the procedure.
A facility failed to notify the activated Medical Power of Attorney (MDPOA) of a resident about the discontinuation of rehabilitation services, as required for informed health care decisions. The Advance Beneficiary Notice (ABN) was incorrectly provided to the resident instead of the MDPOA, preventing the opportunity to appeal the decision. The Director of Rehabilitation and Director of Nursing acknowledged the oversight.
A resident with intact cognition and specific care preferences was not respected when a male CNA checked her brief for wetness, despite her care plan specifying no male CNAs for certain care. Staff interviews revealed a lack of awareness and communication about the resident's preferences, leading to a failure in honoring her choice.
A facility failed to implement a comprehensive care plan for enhanced barrier precautions (EBP) for a resident with multiple diagnoses, including Parkinson's and diabetes with a foot ulcer. The care plan required staff to wear a gown and gloves during wound care, but an LPN did not follow these precautions, as observed during a wound care session. Interviews with facility staff confirmed the care plan was not followed, potentially putting the resident and others at risk for infections.
A facility failed to follow its infection control program for a resident with wounds, as an LPN did not adhere to enhanced barrier precautions. The LPN entered the resident's room without sanitizing hands or wearing a gown, did not clean the overbed table before placing supplies, and failed to change gloves or wash hands at appropriate times during wound care. Interviews revealed a lack of adherence to infection control training and protocols, potentially risking infection spread.
The facility failed to ensure proper infection control practices, as a nurse used an alcohol wipe instead of a disinfectant wipe on a shared glucometer between residents, and a laundry aide handled clean linen without removing soiled PPE. These actions were against facility policies, potentially exposing residents to infections.
The facility failed to provide adequate pressure ulcer care for four residents, as their pressure injuries were not comprehensively assessed upon admission, and their air mattresses were not set according to their weight. This led to inconsistent and inadequate care for residents with pressure injuries.
A resident experienced a significant weight loss of 23 pounds or 10.7% in 8 days, which was not addressed by the dietician or reported to the physician. Despite daily weight monitoring and a care plan in place, the facility failed to take appropriate action to manage the resident's nutritional needs.
Two residents were administered insulin in public areas without privacy, contrary to facility policy. An LPN administered insulin to one resident in a hallway and checked another's blood sugar and administered insulin in a TV room, both in the presence of other residents. This issue had been previously raised in a Resident Council meeting.
Two residents with non-pressure wounds were not comprehensively assessed upon admission, leading to inadequate documentation and care. Initial assessments lacked depth measurements and accurate wound descriptions, with discrepancies in wound locations. Comprehensive assessments were delayed until the Wound Physician's evaluation.
A resident with hemiplegia and spastic hemiparesis was not consistently provided with a left hand splint as required by their care plan, leading to a deficiency in care. Despite the care plan's directive to apply the splint for 6-8 hours daily, it was documented as worn only 9 times over three months. Staff noted the resident's occasional refusal to wear the splint, but these instances were not properly documented or communicated to the occupational therapist or physician, contrary to facility policy.
A resident with Type 2 Diabetes Mellitus did not receive their prescribed Lantus insulin injections on three occasions due to RN-K's decision to hold the medication based on low blood sugar readings, without a physician's order. The facility's policy requires medications to be administered as ordered, and the DON confirmed that any concerns should be communicated to the physician. No documentation was found to support the decision to hold the insulin.
Failure to Monitor and Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor and document a resident's fluid intake in accordance with a physician's order for a 1500 milliliter (ml) fluid restriction. The resident, who had a medical history of chronic kidney disease and congestive heart failure, was admitted with a care plan and physician's order specifying the fluid restriction. Despite these orders, documentation from both the Treatment Administration Record (TAR) and meal intake records showed that the resident consistently consumed fluids in excess of the prescribed limit on multiple days. Interviews with facility staff revealed inconsistencies and gaps in the monitoring process. The Registered Dietitian calculated the daily fluid amounts to be provided by nursing and dietary staff but did not monitor the actual amounts nursing provided. Nursing staff, including RNs and LPNs, documented fluids given during medication administration on the TAR and relied on nurse aides to report meal intake, but there was no comprehensive system to total the fluids from all sources. The Unit Manager acknowledged that he did not add up the total fluids from both medication administration and meals, and only reviewed the TAR, excluding meal intake documentation by nurse aides. The Director of Nursing confirmed that due to inconsistent and incomplete monitoring, it was difficult to determine if the resident's fluid intake adhered to the physician's order. The Medical Director noted that while the resident had a potential for fluid overload, the significance of exceeding the fluid restriction would depend on clinical symptoms or lab values, which were not reported as problematic in this case. The deficiency was attributed to the lack of a coordinated and thorough monitoring process to ensure compliance with the fluid restriction order.
Failure to Revise Care Plan After Catheter Re-Insertion
Penalty
Summary
A deficiency occurred when the facility failed to revise the care plan for a resident after a significant change in condition. The resident, who had diagnoses including Alzheimer's disease, dementia, type 2 diabetes mellitus, major depressive disorder, chronic kidney disease stage 3, and benign prostatic hyperplasia, was admitted on hospice care and initially had a Foley catheter in place. The care plan for the indwelling Foley catheter was resolved after the catheter was removed. However, following an episode of urinary retention, the resident's catheter was re-inserted, but the care plan was not updated or re-initiated to reflect this change. Surveyor observations and record reviews confirmed that the resident continued to have a catheter in place, as evidenced by direct observation and progress notes documenting the re-insertion. Interviews with facility staff, including the registered nurse unit manager and the director of nursing, revealed that care plans are typically reviewed during daily interdisciplinary team meetings, especially when a resident experiences a change in status. Despite this process, the care plan for the resident was not revised after the catheter was re-inserted, and staff acknowledged that this oversight should have been addressed at the time of the status change.
Expired Medications Found in Medication Storage Room
Penalty
Summary
Surveyors observed that the facility failed to ensure that drugs and biologicals in one of two medication storage rooms were not expired. During an inspection of the 2nd floor medication room (2-East), expired stock medications were found in the cabinet, including a bottle of Calcium with Vitamin D with an open date of 11/22 and an expiration date of 7/2025, two unopened bottles of Aspirin 325 mg with an expiration date of 6/2025, and three bottles of Iron 27 mg (one opened with an open date of 1/23/2025 and expiration date of 4/2025, and two unopened with expiration dates of 4/2025). These findings indicate that expired medications were present and accessible in the medication storage area. When interviewed, the registered nurse unit manager (RNUM) stated that they had checked the cabinets upon starting employment in July 2025 but must have missed the expired medications. The RNUM indicated that while anyone could check for expired medications, it was ultimately their responsibility to ensure the task was completed. The RNUM was unsure of the frequency of these checks but guessed they occurred monthly. The director of nursing (DON) confirmed that medication rooms should be checked often and that expired medications should not remain in the medication rooms.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including sepsis, Myasthenia, subdural hemorrhage, epilepsy, abnormal posture, and colostomy, was admitted to the facility and required total assistance with activities of daily living such as toileting, showering, dressing, and transfers. According to the resident's care plan and Minimum Data Set (MDS), showers were scheduled every Friday on the evening shift. Documentation and nursing notes revealed that the resident did not receive the scheduled shower on 1/31/25, resulting in a two-week period without a shower or bath, contrary to the established plan of care. The deficiency was confirmed through review of the resident's records and interviews with the RN Unit Manager and interim DON, both of whom acknowledged the missed shower and the extended period without bathing. No additional information or explanation for the missed care was provided in the report.
Failure to Provide Comprehensive Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for two residents, resulting in the development and inadequate management of pressure ulcers. One resident, who was admitted without open wounds but assessed as at risk for pressure injuries, developed a deep tissue injury to the left heel and a pressure injury to the sacrum during their stay. Comprehensive assessments were not completed when these wounds were discovered, and the care plan was not individualized or updated to reflect the resident's specific risk factors and needs. Documentation of wound assessments lacked essential details such as staging, wound bed description, and surrounding skin assessment. The care plan interventions were generic and did not address the resident's immobility and incontinence, which were identified as primary risk factors. The first comprehensive wound assessment was not performed until several days after the wounds were identified, and only after the wound physician evaluated the resident. Another resident developed an unstageable pressure injury to the right calf, but a comprehensive assessment was not performed at the time of discovery. Weekly wound measurements failed to include depth, and there was no documentation of the wound bed, making it impossible to determine if the wound was improving or declining. The wound was not assessed with all required components, such as stage, length, width, depth, and a complete description of the wound bed. The registered dietitian was not aware of the pressure injury when it was discovered, and the wound physician did not see the resident as indicated. Documentation and care planning for this resident also lacked specificity and completeness, with interventions not tailored to the resident's needs and incomplete wound monitoring. The facility's policy required comprehensive skin and wound assessments, individualized care planning, and regular monitoring for residents at risk of pressure injuries. However, these procedures were not consistently followed for the residents in question. The lack of timely and thorough assessments, incomplete documentation, and failure to individualize care plans contributed to the deficiencies identified by surveyors.
Failure to Provide Adequate Supervision and Personalized Fall Prevention
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, specifically falls. Both residents experienced multiple unwitnessed falls, and the facility did not conduct thorough investigations to determine the root causes of each incident. For one resident, there were repeated falls over a period of time, with documentation showing confusion, impaired mobility, and medication side effects as risk factors. Despite these known risks, the facility did not consistently update or personalize care plans to address specific contributing factors such as toileting needs, proper footwear, or the placement and visibility of fall prevention signage. Interventions were often generic, such as ensuring the call light was within reach, but these were not always implemented effectively or tailored to the resident's individual needs, such as visual impairments or cognitive deficits. In several instances, the facility's post-fall assessments lacked critical information, including when the resident was last observed, when toileting care was last provided, staff statements, and whether the call light was accessible at the time of the fall. The documentation also failed to clarify the circumstances leading up to the falls, such as how the resident moved to the location where the fall occurred or whether assistive devices were used appropriately. For example, one resident was found on the bathroom floor without clear documentation of how they got there, and another was found on the floor with an unlocked wheelchair, but the investigation did not address why the wheelchair was not locked or whether staff had checked on the resident as required. The facility's interdisciplinary team meetings and care plan updates often occurred after multiple falls had already taken place, and interventions were sometimes implemented late or not evaluated for effectiveness. Visual aids intended to prevent falls were not placed in locations visible to the residents, and assistive devices such as fall mats were introduced without documented assessments of need. The lack of comprehensive root cause analysis and failure to personalize interventions contributed to repeated falls and demonstrated inadequate supervision and hazard mitigation for residents at risk.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
During an observation of wound care for a resident with multiple complex medical conditions, including cerebral palsy, protein-calorie malnutrition, and a history of deep tissue injuries, a Licensed Practical Nurse (LPN) failed to maintain proper hand hygiene at several critical points. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was receiving wound care for a pressure injury on the right calf. The LPN was observed touching potentially contaminated surfaces, such as the garbage can and the resident's heel boots, and handling wound dressings and supplies without performing hand hygiene between dirty and clean tasks. The LPN also changed gloves without performing hand hygiene in between, contrary to facility policy and accepted standards of infection prevention. The facility's hand hygiene policy required staff to perform hand hygiene before and after glove use, after handling contaminated objects, and when moving from contaminated to clean body sites. Despite these requirements, the LPN did not perform hand hygiene after removing the old dressing, after cleansing the wound, after removing gloves, or after completing the wound care. The LPN acknowledged typically using hand sanitizer between glove changes but did not have any available during the observed procedure. The Director of Nursing confirmed that hand hygiene should have been performed throughout the wound care process.
Failure to Notify Activated Responsible Party of Therapy Discontinuation
Penalty
Summary
The facility failed to notify the family member and Activated Responsible Party (FM1) of a resident (R1) about the discontinuation of rehabilitation services, which is a requirement for making informed health care decisions. R1 was admitted to the facility with FM1 as the activated Medical Power of Attorney (MDPOA) due to R1's incapacity to make her own health care decisions, as documented by two physicians. Despite this, the facility provided the Advance Beneficiary Notice (ABN) regarding the end of rehabilitation services directly to R1, who was cognitively intact but not legally authorized to make such decisions, instead of FM1. The facility's policy mandates notifying the resident's representative of any changes requiring notification, which was not adhered to in this case. The Director of Rehabilitation confirmed that the ABN was signed by R1 rather than FM1, acknowledging the oversight. The Director of Nursing also stated that the expectation was for the ABN notice to be provided to FM1, given her status as R1's activated MDPOA. This failure to notify FM1 prevented her from having the opportunity to appeal the discontinuation of therapy services, which she believed could have benefited R1.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference to not have male Certified Nursing Assistants (CNAs) provide certain types of care, as outlined in her care plan. The resident, who had intact cognition and was admitted with diagnoses of diabetes and chronic kidney disease stage four, had a care plan specifying that no male CNAs should perform peri care or bathing. However, on one occasion, a male CNA entered the resident's room twice during the night to check her brief for wetness, which the resident found unacceptable. The CNA did not perform peri care but checked the brief for wetness, which the resident perceived as a violation of her preference. Interviews with staff revealed a lack of awareness and communication regarding the resident's preferences. The Registered Nurse (RN) on duty was unaware of the resident's preference, and the Unit Manager, who was responsible for scheduling, acknowledged that the resident's son had informed them of the preference upon admission. The Director of Nursing (DON) confirmed that the care plan specified no male CNAs for bathing and peri care, but there was a misunderstanding about whether checking the brief constituted peri care. This incident highlights a breakdown in communication and adherence to the resident's care plan, leading to the failure to respect the resident's preferences.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement a comprehensive care plan for enhanced barrier precautions (EBP) for a resident with multiple diagnoses, including Parkinson's, diabetes with a foot ulcer, hypertension, and a cerebral vascular accident. The resident's care plan, initiated on 09/27/24, included a requirement for EBP due to wounds, specifying that staff should wear a gown and gloves during wound care. However, during an observation on 10/22/24, an LPN did not wash or sanitize hands before entering the resident's room, which had EBP signage posted. Additionally, the LPN did not wear a gown while performing wound care on the resident's left heel and buttock, contrary to the care plan and posted instructions. Interviews with facility staff, including the MDS Coordinator, Administrator, and Director of Nursing, confirmed that the care plan for EBP was not followed. The MDS Coordinator stated that EBP should have been utilized as per the care plan, and the Administrator and Director of Nursing acknowledged that care plans should be adhered to and modified as needed to meet residents' needs. The failure to implement the EBP care plan had the potential to put the resident and others at risk for infections.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding enhanced barrier precautions (EBP) for a resident with a sacral wound and a left heel wound. The facility's policy required that wound care be conducted in a manner to minimize infection risk, including setting up a clean field, using no-touch techniques, and wearing appropriate personal protective equipment (PPE). However, during an observation, an LPN did not wash or sanitize his hands before entering the resident's room, which had a sign indicating the need for EBP, including wearing a gown and gloves. The LPN did not wear a gown during the wound treatment, contrary to the facility's policy and the posted precautions. The LPN also failed to clean the overbed table before placing supplies on it and did not use a barrier, despite the table being cluttered with personal items. During the wound care process, the LPN did not change gloves or wash hands at appropriate times, such as after removing the old dressing and before applying new ointment and dressings. The LPN used the same gloved finger to apply ointment after cleaning the wound, which was against the recommended practice of using a Q-Tip. Additionally, the LPN placed soiled items, such as a dirty washcloth and old bandages, inappropriately on the bed and floor, rather than disposing of them in a garbage can. Interviews with the LPN and the Director of Nursing (DON) revealed a lack of adherence to the facility's infection control training and protocols. The LPN admitted to missing the EBP sign and not following the correct procedures, while the DON confirmed the expected practices, such as wearing gowns and gloves, cleaning surfaces, and proper disposal of waste. The DON also noted that the Santyl ointment should have been applied with a Q-Tip, not a gloved finger. Despite the training provided, the LPN's actions during the wound care process did not align with the facility's infection control policies, potentially putting residents at risk for infection spread.
Infection Control Deficiencies in Glucometer Use and Laundry Handling
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections. A Registered Nurse (RN) was observed using an alcohol wipe instead of a disinfectant wipe to clean a shared glucometer between residents. This practice was contrary to the facility's policy and the manufacturer's instructions, which require the use of a validated disinfecting wipe to clean the glucometer between each patient. The RN admitted to using the glucometer on three residents without proper disinfection, potentially exposing them to blood-borne pathogens, although none of the affected residents had such pathogens. Additionally, the facility did not adhere to proper infection control procedures in the laundry department. A Laundry Aide was observed handling clean linen while still wearing a gown and gloves that had been used to handle soiled laundry. Despite being reminded by the Director of Housekeeping/Laundry to remove the soiled personal protective equipment (PPE) before handling clean items, the aide proceeded without doing so. This action was against the facility's policy, which mandates the separation of soiled and clean laundry and proper PPE usage to prevent cross-contamination.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received care consistent with professional standards of practice to promote healing. Specifically, four residents with pressure injuries were not comprehensively assessed upon admission, and their air mattresses were not set according to their weight. This deficiency was observed in residents R188, R62, R14, and R12, who had varying degrees of pressure injuries and required specific interventions to promote healing and prevent further deterioration of their conditions. Resident R188 was admitted with multiple pressure injuries, including Stage 3 pressure injuries on the sacrum and unstageable pressure injuries on the left heel and left toe. The initial assessments were inconsistent, with discrepancies in wound measurements and locations. Additionally, R188's air mattress was set at 360 pounds, significantly higher than the resident's actual weight of 172 pounds. This incorrect setting was not addressed until six days after admission, during which time the pressure injuries were not comprehensively assessed or documented. Residents R62, R14, and R12 also had pressure injuries and were observed with air mattresses set incorrectly according to their weights. R62's mattress was set between 240 and 280 pounds, while the resident weighed 190.5 pounds. R14's mattress was set at 320 pounds, despite the resident weighing 163.5 pounds. Similarly, R12's mattress was set at 180 pounds, while the resident weighed 114 pounds. In all cases, there was no documentation or assessment to justify the mattress settings differing from the residents' weights, leading to inadequate pressure ulcer care and prevention measures for these residents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility did not ensure that a resident received the necessary services to assist with nutritional maintenance, resulting in a significant weight loss of 23 pounds or 10.7% in 8 days. The resident, who had diagnoses including Diabetes Type 2, Dysphasia, and Dementia, was on a tube feeding regimen that was adjusted to include a mechanical soft diet. Despite the significant weight loss, there was no notification to the resident's physician, and the dietician did not assess the new weight loss or request a reweigh. The last nutritional assessment was conducted on 3/21/24, and the resident's weight was stable at that time. The dietician acknowledged the significant weight loss but did not take appropriate action to address it. The facility's policy on weight monitoring defines a significant change in weight as a 5% change in one month, requiring physician notification and dietician consultation. However, the resident's care plan, which was last updated on 4/19/24, did not reflect any interventions for the significant weight loss that occurred afterward. The resident's weights were recorded daily, showing a consistent decline, but this was not addressed by the facility staff. The dietician suggested that the use of different types of scales might have contributed to the issue but did not take further steps to resolve it. The findings were shared with the facility's Administrator and Director of Nurses, but no additional information was provided to address the deficiency.
Lack of Privacy During Insulin Administration
Penalty
Summary
The facility failed to treat residents with dignity during the administration of insulin, as observed by surveyors. Two residents, identified as R33 and R55, were administered insulin in public areas without privacy. R33 received insulin in the hallway by the nurses' station, while R55 had their blood sugar checked and insulin administered in the TV room, both instances occurring in the presence of other residents. The facility's policy on insulin administration, which mandates explaining the procedure and providing privacy, was not followed by LPN-G. The issue of insulin being administered in public spaces had been previously raised in a Resident Council meeting, where residents expressed concerns about insulin being given in the dining room. Despite this, the practice continued, as evidenced by the surveyor's observations. The Director of Nursing acknowledged that LPN-G was aware that blood sugar checks and insulin administration should not occur in public spaces, yet the deficiency persisted.
Inadequate Wound Assessment on Admission
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds. Two residents, identified as R188 and R190, were admitted with non-pressure injuries that were not comprehensively assessed upon admission. The facility's policy required a full body skin assessment by a licensed or registered nurse upon admission, but this was not adequately performed for these residents. Resident R188 was admitted with multiple diagnoses and had wounds on the dorsal aspect of the left foot and fifth metatarsal, as well as other areas. However, the initial assessments did not include comprehensive documentation of wound depth or characteristics. The wound on the left dorsal foot was not documented at all, and there were discrepancies in the documentation regarding the location of the wounds. It took six days after admission for a comprehensive assessment to be conducted by the Wound Physician. Similarly, Resident R190 was admitted with several non-pressure wounds, including a diabetic ulcer and venous ulcers. The initial documentation by the facility was inconsistent with the hospital's records, with errors in wound location and lack of depth measurements or tissue type descriptions. The facility's documentation was difficult to follow, and it was not until the Wound Physician's assessment that more accurate and detailed information was recorded. The facility's process for assessing and documenting wounds on admission was inadequate, leading to deficiencies in care.
Failure to Apply Splint for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. The resident, who has hemiplegia and spastic hemiparesis affecting the left side following a stroke, was supposed to have a left hand splint applied for 6-8 hours daily as per their care plan. However, the splint was not consistently applied, with documentation showing it was worn only 9 times from February to April 2024. Observations by the surveyor revealed that the resident was frequently seen without the splint during various times of the day. Interviews with nursing staff indicated that the resident sometimes refused to wear the splint, but there was no consistent documentation of these refusals or communication with the occupational therapist or physician about the resident's non-compliance. The occupational therapist was unaware of the resident's infrequent use of the splint and had not observed any decline in the resident's condition. The facility's policy required that refusals be documented and communicated to the physician or therapist, but this was not done. The Director of Nursing confirmed that staff should notify the doctor or therapist if a resident consistently refuses to wear a splint.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure the accurate administration of medications for a resident with Type 2 Diabetes Mellitus, identified as R15. The resident had a physician's order for a daily Lantus injection, a long-acting insulin, which was not administered on three separate occasions by RN-K. The facility's policy requires medications to be administered as ordered by the physician, yet RN-K did not follow the MD order on 4/10/24, 4/18/24, and 4/24/24. RN-K held the Lantus injections based on her judgment of the resident's blood sugar levels, which were recorded as low on those dates, without any documented physician's order to do so. During interviews, RN-K stated that she would hold the Lantus if the resident's blood sugar was too low, even without a physician's directive, and would notify the physician only if the resident was symptomatic. However, the Director of Nursing (DON)-B confirmed that the protocol requires following the MD order and notifying the physician if there are concerns about administering Lantus. The surveyor found no documentation of a physician's order to hold the Lantus on the specified dates, and the DON-B acknowledged that a nurse would need an order to hold the insulin. The deficiency was discussed with the Nursing Home Administrator and the DON, but no further information was provided at that time.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with 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.
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.
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 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.
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.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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