Congregational Home, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Brookfield, Wisconsin.
- Location
- 13900 W Burleigh Rd, Brookfield, Wisconsin 53005
- CMS Provider Number
- 525700
- Inspections on file
- 15
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Congregational Home, Inc. during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident was not assessed completely and in a timely manner upon admission and at the required periodic intervals, as mandated by regulations.
The facility did not encode and transmit a resident’s assessment data to the State within the required 7-day period following assessment, as identified through record review.
Two residents did not have their quarterly MDS assessments completed within the required timeframe. The sole full-time MDS Coordinator was unable to keep up with all assessments due to lack of assistance, prioritizing Medicare MDS assessments and leaving quarterly assessments delayed or incomplete. The issue was acknowledged by facility leadership.
A resident with significant medical needs and a high risk for falls was rolled away from a CNA during incontinence care, contrary to facility policy requiring residents to be rolled toward the caregiver. This action caused the resident to fall from the bed into the space between the bed and the wall. The incident occurred despite clear facility protocols and staff expectations for safe resident handling.
A facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. A resident and their spouse filed a grievance about a care concern, which was later deemed neglectful and abusive by the spouse. The facility's social worker received an email about the allegation during a holiday weekend but did not report it until after the weekend, violating the facility's policy on timely reporting of such incidents.
A resident with Multiple Sclerosis and spasticity did not consistently receive prescribed ROM exercises twice daily, as facility staff failed to document the completion of these exercises. The resident's care plan lacked measurable goals, and some CNAs were hesitant to perform the exercises. The facility's Director of Nursing and Nursing Care Manager acknowledged the lack of documentation and a comprehensive care plan.
A resident with severe cognitive impairment and multiple medical conditions experienced multiple falls due to inadequate supervision and improper use of a Broda chair. The facility failed to thoroughly investigate falls, update care plans promptly, and ensure interventions were consistently implemented, despite the resident's high fall risk.
A resident at high risk for pressure injuries was not provided with an individualized care plan or consistent wound assessments, leading to the development of a deep tissue injury. The facility failed to document refusals of care and did not update the care plan to address the new injury.
The facility failed to ensure food safety and sanitation standards were met. Staff members were observed not wearing required beard hair restraints and handling ready-to-eat food with contaminated gloves, affecting the quality of food service for residents.
A resident with a foley catheter and bed canes did not have an individualized comprehensive care plan addressing these needs. Despite facility policy requiring such plans, the resident's care plan lacked specific interventions. The nursing care manager and director of nursing confirmed the oversight.
A resident experienced two falls from their recliner, and the facility did not thoroughly investigate the falls or update the resident's care plan with new interventions to prevent future falls. The facility's Falls policy and procedure were not followed, and the resident's fall risk admission assessment was incomplete. The Director of Nursing acknowledged the lack of thorough investigation and care plan updates.
The facility failed to document attempts to use appropriate alternatives and did not complete necessary assessments and obtain informed consent before installing bed rails for two residents. The Director of Nursing and Nursing Care Manager confirmed the deficiencies.
A resident admitted on hospice care did not have a physician certification of terminal illness, and the facility failed to designate a liaison between the facility and the hospice provider. The resident expressed frustration about unmet needs, and the hospice binder lacked necessary documentation. Facility staff were unaware of the missing certification and hospice order, leading to ineffective communication and coordination of care.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Complete Timely Resident Assessments
Penalty
Summary
A deficiency was identified when the facility failed to assess a resident completely and in a timely manner upon admission and then periodically, at least every 12 months, as required. The report notes that the necessary comprehensive assessment was not conducted within the specified timeframes, which constitutes noncompliance with assessment regulations.
Failure to Timely Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. This deficiency was identified based on a review of facility records, which showed that required assessment data were not submitted to the State in the specified timeframe. The report does not provide additional details about specific residents or their medical conditions at the time of the deficiency.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for two of twelve residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, quarterly MDS assessments must be completed at least every 92 days following the previous OBRA assessment, with the completion date no later than 14 days after the Assessment Reference Date (ARD). For one resident, the quarterly MDS assessment was completed 23 days after the required due date. For another resident, the quarterly MDS assessment was still in progress and not completed by the specified deadline. The MDS Coordinator reported being the only full-time staff member responsible for MDS assessments and stated an inability to keep up with all required assessments due to lack of assistance. The Coordinator indicated that priority was being given to Medicare MDS assessments, resulting in quarterly assessments being delayed. During the Coordinator's absence, a pool nurse was covering the role, and the facility was in the process of training another RN for the position. The issue of late and incomplete MDS assessments was acknowledged by the MDS Coordinator and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Adequate Supervision During Incontinence Care Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during incontinence care for a resident with multiple medical conditions, including vascular dementia, chronic kidney disease, and a history of falls. The resident was assessed as being at high risk for falls and was dependent on staff for activities of daily living, mobility, and transfers. During the incident, the CNA rolled the resident away from themselves while the bed was positioned next to the wall, contrary to facility policy, which states that residents should be rolled toward the caregiver when only one staff member is assisting. As a result, the resident rolled off the bed and onto the floor, landing in the space between the bed and the wall. The resident did not sustain an injury from the fall. Interviews with multiple CNAs and nursing leadership confirmed that the expectation is to roll residents toward the caregiver during care when only one staff member is present. The CNA involved in the incident did not follow this protocol, and there was uncertainty about whether the bed was properly positioned or if the brakes were locked at the time of the incident. The facility's policy and staff interviews consistently indicated that the correct procedure was not followed, leading to the resident's fall.
Delayed Reporting of Neglect Allegation
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. A resident and their spouse filed a grievance with the facility's social worker regarding a care concern that occurred on a specific date. The grievance was investigated, and the results were communicated to the resident and their spouse. However, during the Thanksgiving holiday weekend, the spouse sent an email to the social worker, indicating that they believed the incident was neglectful and abusive. The facility did not report this allegation to the State Agency until after the holiday weekend, which was beyond the required reporting timeframe. The facility's policy mandates that allegations of abuse, neglect, exploitation, or mistreatment must be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. Despite this policy, the facility did not have a process in place to address potential abuse or neglect concerns during non-working hours, such as weekends or holidays. The social worker, who was responsible for receiving and acting on such reports, did not check emails during the holiday weekend, leading to a delay in reporting the allegation to the State Agency. The resident involved in the incident had a medical history that included Multiple Sclerosis, Demyelinating Disease of the Central Nervous System, and Spastic Hemiplegia. The resident's cognition was intact, and they were responsible for themselves. The delay in reporting the allegation of neglect was identified during a surveyor's investigation, which included interviews with the resident, their spouse, and facility staff. The facility's failure to report the allegation in a timely manner was a deficiency noted by the surveyor.
Failure to Ensure Consistent ROM Exercises for Resident with Spasticity
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their condition. The resident, who has a diagnosis of Multiple Sclerosis with spasticity, reported to the surveyor that they do not always receive assistance from facility staff to complete their prescribed stretching and range of motion (ROM) exercises twice daily, as indicated in their Certified Nursing Assistant (CNA) Kardex. The facility staff did not document when these exercises were completed, and the resident's care plan lacked measurable goals and interventions related to their spasticity and ROM. The resident's medical records and interviews with facility staff revealed inconsistencies in the implementation of the prescribed ROM exercises. Although the resident's CNA Kardex included detailed instructions for morning and afternoon stretches, there was no documentation in the electronic medical record to confirm that these exercises were being performed. Interviews with CNAs and the Nursing Care Manager indicated that while some staff were aware of the exercise requirements, there was no formal documentation process in place to verify completion. Additionally, some CNAs expressed reluctance or fear in performing the exercises, which may have contributed to the inconsistency in care. The facility's Director of Nursing and Nursing Care Manager acknowledged the lack of documentation and the absence of a comprehensive care plan with measurable goals for the resident's ROM exercises. Despite the resident's ability to communicate their needs and report any lapses in care, the facility did not have a restorative program in place to ensure consistent implementation of the prescribed exercises. This deficiency highlights a gap in the facility's processes for monitoring and documenting the care provided to residents with specific therapeutic needs.
Inadequate Supervision and Care Plan Updates Lead to Multiple Falls
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices to prevent falls for a resident with severe cognitive impairment and multiple medical conditions, including dementia, anxiety disorder, and epilepsy. The resident, who was non-ambulatory and required a Broda chair for safety, experienced multiple falls that were not thoroughly investigated. The facility's policy required comprehensive post-fall assessments and updates to the care plan, but these were not consistently followed. The resident's falls were often unwitnessed, and there was a lack of documentation regarding the last known activities of the resident or whether prior interventions were in place. The Broda chair, which was supposed to be slightly reclined to prevent sliding, was not always positioned correctly, contributing to the falls. Additionally, the care plan was not promptly updated with new interventions following each fall, and staff statements were frequently missing from post-fall reports. Despite the resident's high risk for falls, as indicated by a Morse fall scale score and a history of previous falls, the facility did not ensure that interventions were consistently implemented or that the care plan was revised in a timely manner. The interdisciplinary team did not adequately follow up on incidents, and there was a lack of communication and documentation regarding the resident's care and supervision needs.
Failure to Provide Comprehensive Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident at high risk for pressure injuries was comprehensively assessed and provided with an individualized care plan to promote healing, prevent infection, and prevent new pressure injuries. The resident, who was admitted with a femur fracture and chronic kidney disease, had a Braden score indicating high risk for pressure injuries. Despite this, the facility did not initiate a turning or repositioning schedule for the resident, who subsequently developed a suspected deep tissue injury to the right heel. The care plan was not updated to address this new injury, and weekly wound assessments were not consistently conducted as required by the facility's policy. Observations by the surveyor noted the resident sitting in a recliner chair with their feet resting directly against the footrest, which could contribute to pressure injury development. The resident's medical records showed consistent measurements of the deep tissue injury over several months, indicating a lack of progress in healing. The facility's Director of Nursing (DON) acknowledged that the unit manager responsible for the resident's care had been terminated for not performing their duties, including weekly wound assessments. Interviews with the DON revealed that the resident often refused repositioning and the use of offloading heel boots, but there was no documentation of these refusals or discussions of the risks versus benefits with the resident or their representative. The Nursing Home Administrator (NHA) and DON were unable to provide additional information or justification for the lack of a comprehensive care plan and consistent wound assessments for the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, Cook-J and Server-L were observed multiple times without wearing beard hair restraints while preparing and handling food in the kitchen. Despite the facility's policy requiring hair restraints to prevent hair from contacting exposed food, both staff members were seen without the necessary beard hair restraints on several occasions. The Certified Dietary Manager (CDM) acknowledged the issue and mentioned that they were waiting for an order of beard restraints, substituting them with hair nets in the meantime. However, the expectation was for staff to always have hair and beards completely covered, which was not adhered to during the observations. Additionally, Server-K was observed handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. This occurred multiple times, including touching the counter, their pants, and a metal cart before handling food meant for residents. The facility's policy states that gloves should be changed between tasks with proper hand washing, but this was not followed. The CDM confirmed that the expectation was for gloves to be changed between tasks, but this was not practiced by Server-K during the surveyor's observations.
Lack of Comprehensive Care Plan for Resident
Penalty
Summary
The facility did not ensure that a resident had an individualized comprehensive plan of care. The resident, who has a foley catheter and uses bed canes, did not have a care plan with specific interventions to address these needs. The facility's policy requires the interdisciplinary team to develop and implement a person-centered comprehensive care plan based on the resident's medical, physical, mental, and psychosocial needs. However, the surveyor found that the resident's care plan did not include interventions for the foley catheter or bed canes, despite these being documented in the resident's baseline care plan. The resident was admitted with diagnoses including malignant neoplasm of the bladder, chronic kidney disease stage 3, anxiety disorder, and restlessness and agitation. The resident is cognitively intact and requires various levels of assistance for daily activities. During the survey, the nursing care manager and the director of nursing confirmed that there were no care plans in place for the resident's foley catheter and bed canes, acknowledging that such care plans should have been developed and implemented. No further information was provided as to why the care plans were missing.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for a resident reviewed for falls. The resident experienced two falls from their recliner on separate occasions. The falls were not thoroughly investigated, and the resident's plan of care was not updated to prevent future falls with person-centered interventions. The facility's Falls policy and procedure were not followed, as the resident's fall risk admission assessment did not determine and document the level of fall risk, and the Morse Fall Scale was not completed as required. The resident's care plan, initiated on admission, included several interventions to prevent falls, such as ensuring the call light was within reach, wearing appropriate footwear, and maintaining a safe environment. However, after the resident's falls, the care plan was not updated with new interventions. The incident notes for both falls lacked documentation on whether the call light was on at the time of the falls or if there was any device in the recliner. Additionally, there were no Interdisciplinary Team (IDT) meeting notes to review the falls. The Director of Nursing acknowledged that a thorough investigation was not completed for both falls and that there were no care plan updates as a result of each fall from the recliner. The facility did not ensure that the resident had updated interventions in place to prevent accidents after experiencing two falls from the recliner. The IDT met to review the falls and implemented a new intervention, but no additional information was provided as to why the facility did not ensure updated interventions after the falls.
Failure to Document Alternatives and Assessments for Bed Rails
Penalty
Summary
The facility failed to provide evidence that it attempted appropriate alternatives before installing bed rails for two residents, R59 and R1. For R59, there was no documentation of a physician's order or a care plan for the use of bed canes. Additionally, the facility did not document any attempts to use appropriate alternatives before installing the bed assist bars. R59, who is cognitively intact, confirmed using the repositioning bars to pull himself up in bed, but the necessary assessments and documentation were missing. For R1, the facility did not update the assessment quarterly to document the risks and benefits of bed rails, nor did it obtain informed consent before the installation of half bed rails. R1's comprehensive care plan and physician orders were outdated and did not reflect the current use of half side rails. The facility also failed to document any attempts to use appropriate alternatives before installing the bed assist bars for R1. R1, who has moderately impaired decision-making skills, confirmed using the half siderails to boost himself up in bed. The facility's policy requires a comprehensive assessment, informed consent, and attempts to use appropriate alternatives before installing bed assist bars. However, these steps were not followed for R59 and R1, leading to deficiencies in the care provided. The Director of Nursing and Nursing Care Manager confirmed the lack of necessary documentation and assessments for both residents.
Failure to Ensure Coordinated Hospice Services
Penalty
Summary
The facility failed to ensure coordinated hospice services for a resident (R59) who was admitted on hospice care. The resident did not have a physician certification of terminal illness, and the facility did not designate a specific individual from the interdisciplinary team to act as a liaison between the facility and the hospice provider. The facility's hospice services policy and procedure require a coordinated plan of care, including a physician order for hospice services and a designated liaison, which were not in place for R59. Additionally, the resident's current physician orders did not include an order for hospice services, and the hospice binder lacked the necessary physician certification of terminal illness. During the survey, the resident expressed frustration and agitation about unmet needs, such as a non-working razor and hearing aids. The surveyor found that the hospice binder contained outdated progress notes and lacked the physician certification of terminal illness. The facility staff, including the Licensed Practical Nurse (LPN) and Social Worker (SW), were unaware of the location of the hospice binder and had not communicated the resident's concerns to the hospice team. The Director of Nursing (DON) and Admissions Director (AD) were also unaware of the missing physician certification and hospice order. The surveyor's interviews with facility staff revealed a lack of communication and coordination between the facility and the hospice provider. The Hospice Social Worker (HSW) confirmed that the resident's concerns had not been communicated, and a new plan of care was needed. The facility had not designated a specific individual to act as a liaison, and the physician certification of terminal illness was not attached to the hospice comprehensive care plan upon the resident's admission. The facility's failure to ensure proper documentation and communication resulted in the resident's care concerns not being addressed effectively.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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