Dove Healthcare - St Croix Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in St Croix Falls, Wisconsin.
- Location
- 750 E Louisiana St, St Croix Falls, Wisconsin 54024
- CMS Provider Number
- 525532
- Inspections on file
- 29
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Dove Healthcare - St Croix Falls during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food service sanitation, including staff not using proper hair restraints, unclean kitchen equipment, personal beverages on food prep counters, improper storage of food under freezer drips, and opened food items without required dating. These failures affected all residents, as they occurred in areas where food for the entire facility is prepared and stored.
The facility did not have an infection prevention and control program in place, as observed and documented by surveyors.
A resident with multiple chronic conditions indicated a preference to receive the RSV vaccine by signing the appropriate consent form, but the vaccine was not administered. The Infection Preventionist confirmed the vaccine was not given and stated it would have required ordering from the pharmacy, acknowledging the resident should have received it as requested.
Two residents did not have current advance directives or documentation of advance care planning in their records, and there was no evidence that they were offered assistance or that their preferences were documented, despite facility policy requiring this. The Social Services Director confirmed the absence of required documentation and follow-up.
Two residents voiced grievances regarding lack of assistance with mobility and dissatisfaction with wound care, but the facility did not follow its grievance policy to investigate, document, or resolve these concerns. Staff acknowledged the complaints but failed to initiate the required grievance process or communicate outcomes to the residents.
A resident with a history of stroke, hemiplegia, and moderate cognitive impairment was found with unexplained swelling and bruising, later requiring hospitalization for a hematoma and pneumothorax. Facility staff did not conduct a risk management investigation or report the injury of unknown origin to the NHA or State Agency, contrary to policy and regulatory requirements.
Two residents did not receive care planned interventions to prevent accidents and falls. One resident, requiring two-person assist and proper use of an EZ stand lift, was transferred by a CNA without fastening the safety strap and without a second staff member, resulting in a fall to the floor. Another resident, assessed as a fall risk and requiring gripper socks at all times, was observed wearing regular socks, and staff were unaware of his care plan requirements. Facility staff did not follow care plans or manufacturer instructions, leading to deficiencies in accident prevention.
A resident with a history of chronic kidney disease, diabetes, and urge incontinence was treated for an acute urinary tract infection with ciprofloxacin without a culture and sensitivity test to confirm the antibiotic's effectiveness. Facility policy requires such testing and review by the Infection Preventionist, but documentation was lacking, and leadership confirmed the omission during the survey.
The facility did not conduct thorough investigations into two separate allegations of staff-to-resident abuse, failing to interview the affected residents, the accused CNA, or other staff and residents who may have relevant information. This lack of comprehensive investigation did not meet the facility's own policy requirements for abuse investigations.
A resident at high risk for pressure injuries developed a deep tissue injury due to the facility's failure to implement preventive measures and conduct timely assessments. Despite being assessed as high risk, the facility did not conduct a readmission skin assessment or update the care plan promptly, leading to the development of a pressure injury.
A facility failed to conduct comprehensive weekly wound assessments for a resident with multiple comorbidities, leading to a deficiency in care standards. The resident, who was readmitted from the hospital, did not receive a timely skin assessment, and an open wound was not comprehensively assessed upon discovery. The wound, identified as facility-acquired MASD, deteriorated over time, with inconsistent and incomplete assessments documented. Staff interviews revealed a lack of full skin assessment and new interventions for urinary incontinence to aid healing.
The facility failed to maintain proper infection control practices, as staff did not perform hand hygiene or use PPE correctly during care for residents on Enhanced Barrier Precautions (EBP). CNAs did not wash hands between glove changes, and RNs did not wear gowns during wound care, contrary to facility policy. The DON acknowledged these deficiencies and indicated that staff education had begun.
A facility failed to notify a resident's physician of elevated blood sugar levels, as required by standing orders. The resident, with a history of diabetes and other conditions, had multiple instances of blood sugar levels exceeding 400, but the facility did not document any physician notification or assessment of the resident's condition. This deficiency was confirmed by the President of Clinical Operations.
Two residents in the facility did not receive regular weekly showers as required, affecting their personal hygiene. One resident, with conditions such as hypertension and diabetes, reported not receiving showers for at least two weeks, with no refusals recorded. Another resident, with mild cognitive concerns, also missed showers for over two weeks. A registered nurse acknowledged issues with shower aides not properly recording showers, leading to uncertainty about whether showers were completed.
A resident's advance directive for CPR was not followed when they were found unresponsive. Staff delayed initiating CPR, and when it was started, it was performed ineffectively. The delay and improper technique contributed to the resident's serious harm.
The facility failed to maintain food safety and sanitation standards, as observed by surveyors. Unsanitary conditions were found in the dish room, including dusty air conditioner blades and fans with black fuzzy substances. Additionally, an employee improperly handled food with contaminated gloves, which was confirmed as incorrect by the Nutritional Services Director. These deficiencies have the potential to affect all 43 residents.
The facility failed to establish a comprehensive Infection Control Program, leading to deficiencies such as an outdated Water Management Plan, inadequate infection surveillance during a COVID-19 outbreak, and failure to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds. The Infection Preventionist and Director of Nursing admitted to incomplete surveillance logs and a lack of training, while staff were observed not using PPE during high-contact care.
The facility failed to ensure the Infection Preventionist (IP) had specialized training in infection prevention and control, affecting all 43 residents. RN D, who served as the IP, did not complete the necessary training and was left to manage the program with limited experience and resources. Significant errors and lack of documentation were found in infection surveillance, and deficiencies were noted in the facility's water management program and vaccination administration.
The facility failed to ensure a comprehensive system for influenza and pneumococcal vaccinations, affecting multiple residents. Documentation was lacking for offering or educating residents about these vaccinations, and declination forms were missing. Interviews with staff revealed that the process for updating and educating residents on vaccinations was incomplete, leading to this deficiency.
The facility failed to offer and educate eight residents on the COVID-19 vaccine, as required. Documentation was lacking for several residents, with no evidence of education or declination forms. Interviews with staff revealed that the process for updating immunizations and providing education was not consistently completed, leading to the deficiency.
A facility failed to notify a resident's physician when blood sugar levels exceeded 400 mg/dl, as required by orders. Despite 12 instances of elevated levels, the order to contact the physician was not visible on the MAR, leading to a lack of communication. Staff interviews confirmed the oversight, and the physician was only contacted twice, not specifically for the elevated levels.
Two residents in an LTC facility were involved in safety deficiencies. One resident, identified as a high fall risk, independently left the facility and drove a personal vehicle without staff knowledge or proper assessment. Another resident, with moderate cognitive impairment, was observed smoking unsupervised with cigarettes and a lighter on their person, against facility policy. These incidents highlight failures in adhering to care plans and enforcing safety protocols.
A resident with a PICC line for IV antibiotics did not receive proper care as staff failed to measure the catheter length before administration and did not use alcohol-based connector locks to prevent infection. The facility's staff acknowledged these oversights, and the DON confirmed expectations for adherence to care plans and infection control practices.
The facility failed to provide written notification to residents or their representatives about hospital transfers and did not inform the State Ombudsman for four residents. This included cases of emergency transfers for psychiatric evaluation, COVID pneumonia, congestive heart failure, possible stroke, and septic shock. The social worker was unaware of the notification requirement, and the Nursing Home Administrator confirmed the lack of compliance.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Potentially hazardous foods were not served at safe temperatures, and there was no evidence of temperature checks or proper documentation, affecting all residents.
The facility failed to ensure that an LPN had the proper licensure in accordance with Wisconsin state law. The LPN had been working full-time without an active Wisconsin nursing license, and the facility did not follow up to confirm the licensure application was completed.
The facility failed to ensure accurate medication administration for four residents, resulting in multiple missed doses and incorrect medications due to transcription errors and process inconsistencies. The DON was unaware of several errors until informed by the surveyor.
The facility failed to assess a resident after a reported fall incident. The resident reported a fall that occurred the previous day, but the nursing staff did not perform an assessment or document the fall. Subsequent assessments revealed a bruise and swelling, but no fractures. Interviews with staff indicated that the standard procedure for handling falls was not followed in this case.
The facility failed to ensure a safe environment by not assessing a resident's ability to use nicotine products after discontinuing their nicotine patch. The resident, diagnosed with hemiplegia and hemiparesis, was observed smoking and had chewing tobacco within reach, but no smoking assessment or care plan was provided.
Failure to Maintain Sanitary Food Service Environment and Practices
Penalty
Summary
Surveyors observed multiple failures in maintaining a safe and sanitary environment in the facility's food service operations. Staff in the food preparation area were seen without proper hair restraints, including one staff member wearing a personal baseball cap and another with a stocking cap not designated for kitchen use. The facility's policy requires clean, designated hair restraints, but staff were unclear on laundering frequency and whether hats were used outside the facility. Additionally, a mixer was found stored with visible food residue inside, indicating it had not been cleaned before storage. Staff were also observed with personal beverages on food preparation counters, contrary to facility policy prohibiting eating and drinking in these areas. Further deficiencies included improper food storage practices. Surveyors found frozen drips on the ceiling of the walk-in freezer, with opened and unsealed boxes of vegetables stored underneath, resulting in ice buildup on and inside the boxes. Opened containers of juice in the juice machine were undated, and staff were unable to confirm when they had been opened. Facility policy requires all opened food and beverages to be labeled with an open or use-by date, but this was not followed. These observations affected all 47 residents in the facility, as the issues were present in areas where food for all residents is prepared and stored.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Administer RSV Vaccine per Resident Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to participate in and make informed decisions about her treatment. The resident, who had a medical history including multiple sclerosis, pneumonitis, and a personal history of Covid-19, was offered the Respiratory Syncytial Virus (RSV) vaccine. She indicated her preference to receive the vaccine by checking 'Yes' and signing the Acknowledgement of Receipt of Vaccine Information Sheet. Despite this documented preference, there was no evidence in her electronic health record that the RSV vaccine was administered. During an interview, the facility's Infection Preventionist confirmed that the resident did not receive the RSV vaccine and explained that the facility would have needed to contact the pharmacy to obtain it, as it was not stocked in-house. The Infection Preventionist also acknowledged that the resident should have received the vaccine according to her expressed wishes. This failure to provide the vaccine as requested was not in accordance with the facility's policies on resident rights and self-determination.
Failure to Document and Facilitate Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' rights to request, refuse, and/or discontinue treatment and to formulate an advance directive were honored, as required by facility policy. For both residents, their charts did not contain current copies of their advance directives or documentation of advanced care planning beyond code status. During record reviews, surveyors were unable to locate copies of the residents' advance directives or Power of Attorney for Health Care (POAHC) in the electronic medical records. Interviews with the Social Services Director confirmed that there was no documentation on file for either resident regarding their advance directives or evidence that assistance was offered or preferences were documented. In one case, documentation indicated that a resident was interested in completing advance directive documents, but there was no evidence that assistance was provided or that this interest was followed up on. The Social Services Director acknowledged that documentation should have been present to show that residents were offered assistance in completing advance directives and that their preferences were recorded. The lack of documentation and follow-up regarding advance care planning for these residents constituted a failure to comply with the facility's own policy and federal requirements.
Failure to Investigate and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for two residents. The policy requires prompt investigation, documentation, and resolution of grievances, overseen by a designated Grievance Official. In both cases, the facility did not document a thorough investigation or resolve the grievances as outlined in their procedures. One resident, who had moderate cognitive impairment and multiple mobility-related diagnoses, expressed concerns about not receiving assistance when moving from the dining room to his room. Progress notes indicated that the resident was upset about not being helped and voiced his intention to report the issue. Staff interviews revealed that the concern was not reported as a grievance, and the required documentation and investigation were not completed. The staff acknowledged that the resident frequently expressed such concerns, but no formal grievance process was initiated in response to his repeated complaints. Another resident with a history of diabetic foot ulcers voiced a grievance about wound care, specifically not wanting a particular nurse practitioner to debride her wound due to increased pain. The resident reported her concerns to both the Nursing Home Administrator and a nurse. Although an administrative assistant recognized the concern as a grievance and reported it to the administrator, no grievance form was completed and the facility did not follow up according to its policy. In both cases, the facility did not adhere to its established grievance procedures, failing to ensure prompt investigation, documentation, and communication with the residents involved.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving injuries of unknown origin were reported immediately to the administrator and the State Agency, as required by both facility policy and state law. A resident with a history of cerebral infarction, hemiplegia, difficulty walking, and moderate cognitive impairment was found to have swelling on the right hip and dark purple bruising on the right shoulder and arm. The origin of these injuries was unknown, and the resident was subsequently hospitalized with a hematoma and pneumothorax requiring a chest tube. Despite the facility's policy mandating immediate reporting and investigation of such injuries, there was no documentation of a risk management investigation or notification to the Nursing Home Administrator or State Agency. Interviews with facility staff, including a Registered Nurse/Nurse Manager and the Director of Nursing, confirmed that the expected procedure would have included an assessment, provider notification, investigation, and documentation in risk management. Both staff members acknowledged that this process did not occur for the resident in question. The Nursing Home Administrator also confirmed that the injuries should have been classified as of unknown origin and reported accordingly, but this was not done.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents, as evidenced by two residents who did not have their care planned interventions implemented. One resident, who was assessed and care planned for two-person assistance with an EZ stand lift for transfers, was transferred by a CNA who did not follow the manufacturer’s instructions. The safety strap on the harness was not fastened around the resident’s waist, and the transfer was attempted with only one staff member present. During the transfer, the resident began to slide through the straps and was lowered to the floor, resulting in a change in plane and reported shoulder pain. Multiple staff interviews confirmed that the safety strap was not used as required, and that the resident was not transferred according to her care plan, which specified two-person assistance. Another resident, who had a history of repeated falls and was assessed as a fall risk, was observed without his care planned fall prevention intervention in place. The resident’s care plan and Kardex specified that he should wear gripper socks at all times and not wear shoes due to a wound on his toe. However, the resident was observed in the dining room wearing regular socks, and a CNA admitted to attempting to put shoes on the resident, contrary to the care plan. The resident confirmed that his shoes caused a wound on his toe, and the CNA only provided gripper socks after the surveyor’s intervention. Staff interviews revealed a lack of awareness regarding the resident’s fall risk status and the required interventions. Facility policies required that residents be handled and transferred safely according to their individual care plans and that mechanical lifts be used according to manufacturer instructions. The policies also mandated that fall prevention interventions be implemented and monitored for effectiveness. In both cases, staff failed to follow established care plans and manufacturer guidelines, resulting in residents not receiving the necessary supervision and interventions to prevent accidents and falls.
Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to follow its own standards of practice for antibiotic stewardship by not ensuring that a culture and sensitivity test was performed before prescribing antibiotics for a resident diagnosed with an acute urinary tract infection. The resident, who had a medical history including chronic kidney disease, Type 2 diabetes mellitus, and urge incontinence, experienced symptoms such as pain, itching, and burning in the vaginal area. After being seen in the emergency department, the resident was diagnosed with a urinary tract infection and prescribed ciprofloxacin without evidence of susceptibility testing to confirm the appropriateness of the antibiotic. Facility policy requires that antibiotic use be based on clinical standards, including evaluation of symptoms and, when necessary, obtaining further documentation to support the treatment plan. The Infection Preventionist or designee is responsible for reviewing antibiotic orders, which includes ensuring the necessity and appropriateness of the treatment. During the survey, the Vice President of Clinical Operations confirmed that there was no culture and sensitivity test documented in the resident's electronic health record, acknowledging that such testing should have been completed to ensure the correct antibiotic was prescribed.
Failure to Thoroughly Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of staff-to-resident abuse for two of three residents reviewed for abuse. In the first case, a resident with chronic obstructive pulmonary disease (COPD) reported that an agency CNA was rough when assisting her to bed, specifically stating that the CNA threw her legs onto the bed aggressively. The investigation into this incident did not include an interview with the resident, the alleged CNA, or any other staff or residents who may have witnessed or experienced similar care from the CNA. There was also no documentation of attempts to interview the alleged CNA. In the second case, a resident with chronic kidney disease reported that an agency staff member on the overnight shift told her to "hold it" instead of assisting her to the restroom. The investigation similarly lacked interviews with the resident, the alleged CNA, or any other staff or residents regarding the care provided by the CNA in question. The facility's policy requires thorough, well-documented, and immediate investigations, including interviews with all relevant parties, but these steps were not followed. The administrator acknowledged that the investigations were incomplete and that there was no documentation of an interview with the alleged CNA.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident identified as being at risk for pressure injuries. The resident, who was admitted without a pressure injury, developed a deep tissue injury (DTI) on the left heel. The facility did not implement preventive measures such as heel boots before the development of the DTI and failed to complete a comprehensive assessment with staging of the pressure injury upon its discovery. The resident had a history of Alzheimer's disease, type 2 diabetes mellitus, dementia with behavioral disturbance, weakness, depression, and reduced mobility, which contributed to their risk for pressure injuries. Despite being assessed as high risk for pressure injuries, the facility did not conduct a readmission skin assessment upon the resident's return from the hospital. Preventive interventions, such as floating heels and the use of protective boots, were not timely implemented, and the care plan was not updated promptly to promote healing. The facility's documentation and interviews with staff revealed a lack of timely and systematic approach in assessing and managing the resident's pressure injury. The Director of Nursing and Nurse Practitioner indicated that the facility relied on the NP for wound staging and did not follow through with necessary interventions. The facility's failure to adhere to its own policy and professional standards of practice resulted in the development of a pressure injury that could have been prevented with appropriate care and timely interventions.
Failure to Conduct Comprehensive Wound Assessments
Penalty
Summary
The facility failed to complete comprehensive weekly wound assessments for a resident, identified as R1, which led to a deficiency in ensuring that residents receive treatment and care in accordance with professional standards of practice. R1, who was admitted with multiple diagnoses including Alzheimer's disease, type 2 diabetes mellitus, and reduced mobility, did not receive a comprehensive assessment of a skin injury upon discovery, nor were timely interventions initiated to promote healing. The facility's policy required wound assessments to be documented upon admission, weekly, and as needed if the resident or wound condition deteriorates, but this was not adhered to. R1 was readmitted to the facility from the hospital, and the staff failed to complete a readmission skin assessment. Two days later, a skin observation note indicated that the skin was intact, but shortly after, an open area over the coccyx was noted. Despite the discovery of the wound, a comprehensive wound assessment was not completed immediately. The wound clinic nurse practitioner later documented the wound as facility-acquired MASD, with measurements indicating progression and deterioration over time. The facility's weekly wound tracker and progress notes documented the wound's condition, but the assessments were inconsistent and incomplete. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, revealed that there was no full skin assessment upon R1's return from the hospital and no assessment of the wound upon its initial discovery. The facility also failed to implement new interventions for R1's urinary incontinence to promote healing of the MASD. The wound clinic nurse practitioner noted that the wound's progression was affected by R1's reduced mobility, decreased nutrition, and general decline, and indicated that the wounds were unavoidable given the resident's overall condition.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and inadequate use of personal protective equipment (PPE) during resident care. Certified Nursing Assistants (CNAs) F and G did not perform hand hygiene before and after glove changes while providing personal care to a resident on Enhanced Barrier Precautions (EBP) for open wounds. Additionally, Registered Nurse (RN) H failed to maintain proper hand hygiene by using gloved hands to operate a faucet and then proceeded with wound care without changing gloves. The CNAs also neglected to perform hand hygiene after disposing of waste and before assisting another resident. In another instance, RNs I and J did not wear gowns while providing wound care to a resident on EBP for multiple open wounds, despite the facility's policy requiring gown use during such care. The Director of Nursing (DON) acknowledged the need for hand hygiene after glove changes and confirmed that gowns should be worn for residents on EBP and during wound care. The DON indicated that staff education on proper hand hygiene and PPE use had been initiated.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to promptly notify and consult with a resident's physician when there was a significant change in the resident's clinical condition, specifically when blood sugar levels exceeded the threshold. This deficiency was identified for one resident, who was being reviewed for insulin use. The facility's standing orders required notification of the provider if blood glucose results were less than 70 or greater than 400 in a 24-hour timeframe. However, the facility did not adhere to these orders, as evidenced by multiple instances of elevated blood sugar levels that were not reported to the physician. The resident involved had a history of chronic kidney disease stage 3, congestive heart failure, type 2 diabetes mellitus, diabetic neuropathy, and diabetic retinopathy. Despite having a cognitively intact status and receiving insulin injections, the resident's blood sugar levels consistently exceeded the threshold over several days. The medication administration record documented numerous instances of blood sugar levels above 400, yet there was no documentation of physician notification or assessment of the resident's condition during these elevated levels. The facility's failure to notify the physician was confirmed by the President of Clinical Operations, who acknowledged the lack of documentation and the need for physician notification.
Failure to Provide Regular Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out daily living activities received necessary services to maintain good hygiene, specifically in providing regular weekly showers. Two residents, R1 and R7, were affected by this deficiency. R1, who requires substantial assistance for showering due to conditions such as hypertension, diabetes, and arthritis, reported not receiving weekly showers as expected. The shower log for R1 showed a blank entry for a scheduled shower date, and there were no records of refusals or progress notes indicating any issues on that date. Similarly, R7, who also requires substantial assistance and has mild cognitive concerns, had not received a shower for over two weeks. The shower task records for R7 were incomplete, with no indication of refusals or progress notes explaining the missed showers. A registered nurse confirmed that the facility expects residents to receive weekly showers and acknowledged issues with shower aides not properly recording completed showers, making it difficult to verify if showers were missed or completed.
Failure to Follow Resident's CPR Wishes
Penalty
Summary
The facility failed to adhere to a resident's advance directives regarding their code status, resulting in a deficiency. The resident, who had a critical care plan indicating a desire for CPR, was found unresponsive and without a pulse. Despite the resident's wishes, staff did not promptly initiate CPR, and when it was eventually started, it was not performed according to current standards, leading to an ineffective procedure. The incident involved multiple staff members who were present in the resident's room but did not take immediate action. A Licensed Practical Nurse (LPN) refused to perform CPR, citing the resident's age as a reason. When CPR was eventually initiated, it was done half-heartedly and without proper technique, such as placing a backboard under the resident or moving them to a firm surface. The delay in initiating CPR was estimated to be between 10 to 15 minutes, during which time no defibrillator was used. The resident had been experiencing shortness of breath prior to being found unresponsive. Despite the presence of several staff members, there was confusion and a lack of decisive action, which contributed to the delay in providing the necessary life-saving measures. The failure to follow the resident's code status and promptly begin CPR resulted in serious harm and was identified as an immediate jeopardy situation.
Removal Plan
- All staff education of CPR policy, emergency medical services activation, and code status, crash cart location, delegation of duties, crash cart audits, code status audits, and mock code competency.
- Education provided to all staff on CPR policy and Code Blue drills.
- Emergency Documentation form created and placed on both crash carts.
- Audits and restocking of both crash carts.
- Audits of all resident code status.
- Initiation of Code Blue drills for all shifts.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed by surveyors. During an inspection of the dish room, a window air conditioner was found blowing on clean dishes, with visible light gray dust on its blades. Additionally, the exhaust fan above the dishwasher and a wall-mounted fan were observed to have a black, fuzzy substance on them, with similar black fuzzy spots on the wall surrounding the fan. These unsanitary conditions were confirmed by the Nutritional Services Director (NSD), who acknowledged the need for cleaning. Furthermore, improper food handling practices were observed during meal service. An employee, identified as [NAME] J, was seen using the same pair of gloves to handle various food items, including spatulas, sandwiches, and deviled eggs, without changing gloves or using appropriate utensils like tongs. This practice was confirmed as incorrect by the NSD, who stated that tongs should have been used to serve the sandwiches. These actions demonstrate a lack of adherence to food safety protocols, potentially affecting all 43 residents in the facility.
Inadequate Infection Control Program and Surveillance
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, which led to several deficiencies affecting both residents and staff. The facility did not have a clear water management process to prevent the transmission of Legionella infection, as evidenced by the absence of maintenance records, inspections, or flushing of areas of concern. The Water Management Plan was outdated and lacked specific quality measures, such as the identification of stagnation areas or hot spots. The Nursing Home Administrator admitted to using an outdated CDC toolkit and acknowledged the lack of audit logs until late June 2024. Additionally, the facility's infection surveillance was inadequate, particularly during a COVID-19 outbreak from December 2023 to February 2024. The infection control logs were inconsistent and missing critical information, such as residents' identifiers, onset of symptoms, and testing details. The Infection Preventionist, who was also the Director of Nursing, admitted to incomplete surveillance logs and a lack of training in infection prevention. The Director of Nursing acknowledged that the process for tracking infections and antibiotic usage compliance was not in effect and was only beginning to be addressed. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. Surveyors observed that residents on Transmission-Based Precautions did not have appropriate signage or PPE supplies, and staff were not consistently using PPE during high-contact care. The Director of Nursing admitted that the facility's policy did not align with CDC guidance, leading to the removal of EBP for residents who should have been on such precautions.
Inadequate Infection Control Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had specialized training in infection prevention and control, which potentially affected all 43 residents. Registered Nurse (RN) D, who served as the facility's IP until June 2024, admitted to not completing the necessary infection control instructional class to become certified. Although there was a corporation person overseeing the infection control program from January to July 2023, RN D was left to manage the program independently from July 2023 to June 2024. RN D acknowledged a lack of proficiency in infection control surveillance and implementation, citing limited experience and resources. The surveyor's review of documentation revealed significant errors and a lack of documentation during infection surveillance from January 2023 to July 2024. The last known documentation signed by a trained infection preventionist was a line list dated July 2023. Additionally, deficiencies were noted in the facility's water management program and in the administration of Covid, influenza, and pneumococcal vaccinations, which were not consistently offered or given to prevent the spread of infection. These issues were documented under deficiencies F880, F883, and F887.
Deficiency in Vaccination Documentation and Education
Penalty
Summary
The facility failed to maintain a comprehensive system for ensuring residents received influenza and pneumococcal immunizations, affecting 9 out of 13 sampled residents. The surveyor found that the facility did not have documentation of offering or educating residents about these vaccinations, nor did they have declination forms for those who refused. Specific residents, including R40, R24, R11, R1, R2, R21, R42, R37, and R31, were identified as not having been appropriately informed or offered the vaccinations. For instance, R40 was not documented as having been offered or educated about the vaccinations upon admission, and R1's consent forms lacked evidence of education or completed screening questions. Interviews with the Director of Nursing, a Registered Nurse, and the VP of Clinical Operations revealed that the process for updating and educating residents on vaccinations was incomplete and had been neglected. The staff acknowledged that the task of administering and educating on influenza and pneumococcal vaccinations had fallen through the cracks, resulting in the deficiency. This lack of a systematic approach to immunizations was confirmed by the surveyor's interviews and reviews of resident records.
Failure to Offer and Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that eight residents were offered and educated about the COVID-19 vaccine, as required. The residents involved were not provided with the necessary information or documentation regarding their vaccination status. For instance, Resident 40 was admitted without any documentation of being offered or educated about the COVID-19 vaccine, and there was no declination form in their record. Similarly, Resident 24 was readmitted without documentation of being offered or educated about the vaccine, and no declination form was present. Resident 1 had a consent form signed by their Power of Attorney, but it lacked evidence of education and did not include completed screening questions. Resident 2 had a declination form signed but also lacked documentation of education. The surveyor's review of the immunization records for Residents 21, 42, 37, and 31 revealed that COVID-19 vaccinations were not offered, kept up to date, or accompanied by education for the residents or their Power of Attorneys. Interviews with the Director of Nursing, a Registered Nurse, and the VP of Clinical Operations indicated that the process for updating immunizations and providing education on vaccinations was not being consistently completed throughout the facility. The staff acknowledged that the task of administering or educating on COVID-19 vaccinations had fallen through the cracks, leading to the deficiency identified by the surveyor.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's health status, specifically when blood sugar levels exceeded the threshold specified in the orders. The orders required that the physician be contacted if the resident's blood sugar levels were above 400 mg/dl. However, there were 12 instances in June and July where the resident's blood sugar levels exceeded this threshold, and the physician was not contacted as required. This oversight was discovered during a surveyor's review of the resident's records, which showed no communication with the physician regarding these elevated blood sugar levels. Interviews with facility staff revealed that the order to contact the physician was not visible on the Medical Administration Record (MAR) during medication administration, leading to the oversight. The Registered Nurse (RN) and Director of Nursing (DON) confirmed that the order was not being seen in their system, and an old order with different parameters was no longer active. Although the dietitian and nurse practitioner were informed of the raised blood sugar levels, the physician was only contacted on two occasions, and not specifically for the instances where levels were above 400 mg/dl.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure resident safety and supervision, leading to two significant deficiencies. The first deficiency involved a resident, R301, who was identified as a high fall risk due to multiple medical conditions, including schizophrenia and arthritis. Despite requiring assistance for transfers and ambulation, R301 was observed independently leaving the facility, driving a personal vehicle to a neighboring community, and returning without staff knowledge or proper assessment of car transfer safety. The facility staff, including CNAs and RNs, were unaware of R301's actions and the presence of the resident's car, indicating a lack of communication and monitoring. The second deficiency involved another resident, R25, who had moderate cognitive impairment and respiratory issues. R25 was observed smoking independently with cigarettes and a lighter kept in a pouch on their person, contrary to the facility's smoking policy, which required supervision and storage of smoking materials by staff. Despite being assessed as needing supervision for smoking due to safety concerns, R25 was able to access and use smoking materials without staff intervention, highlighting a failure to enforce the care plan and smoking policy. Both deficiencies demonstrate a lack of adherence to care plans and facility policies designed to ensure resident safety. The facility's failure to conduct necessary assessments and enforce supervision protocols resulted in residents engaging in potentially hazardous activities without appropriate oversight. These lapses in safety measures and communication among staff contributed to the deficiencies identified by the surveyors.
Deficiency in IV Fluid Administration and Infection Control
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident with a Peripherally Inserted Central Catheter (PICC) line. The resident, admitted for short-term rehabilitation with a diagnosis of infection due to an internal right knee prosthesis, required IV antibiotics. The care plan specified that the length of the PICC line should be measured daily before administering antibiotics, and alcohol-based connector locks should be used to prevent infection. However, staff did not measure the PICC line length before administering the antibiotic Daptomycin, as observed by the surveyor. Additionally, the staff did not apply alcohol-based connector locks after administering the IV antibiotics, contrary to the guidelines for preventing central line-associated bloodstream infections. Interviews with the nursing staff and the Director of Nursing (DON) revealed a lack of adherence to the care plan and national standards of practice. The Registered Nurse (RN) involved acknowledged the oversight in not measuring the PICC line length. Another RN indicated that the facility had not ordered the necessary alcohol-based connector caps, which were not included in the PICC line dressing kit. The DON confirmed that the facility was in transition between corporate and pharmacy policies but expected the use of alcohol-based connectors to prevent infection. The deficiency was identified due to these lapses in following the prescribed care plan and infection control practices.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives regarding the reasons for transfers or discharges to hospitals, and did not notify the Office of the State Long Term Care Ombudsman for four residents. This deficiency was identified through interviews and record reviews. For instance, one resident with multiple diagnoses, including PTSD and Alzheimer's, was transferred to a hospital for psychiatric evaluation due to aggressive behavior, but no written notice was provided. Another resident with a history of traumatic subarachnoid hemorrhage and congestive heart failure was transferred twice to a hospital for treatment of COVID pneumonia and congestive heart failure exacerbation, yet the facility failed to notify the resident or their representative in writing or inform the Ombudsman. Additionally, two other residents were transferred to hospitals for medical emergencies, including a possible stroke and septic shock, without receiving written notices of transfer or discharge. The facility's social worker admitted to being unaware of the requirement to notify the Ombudsman and had not done so since her hire date. The Nursing Home Administrator acknowledged the lack of written notices and Ombudsman notifications for these transfers, indicating a systemic issue in the facility's compliance with notification requirements.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a meal distribution observation, the surveyor noted that potentially hazardous foods were not served at temperatures that would reduce the chance of illness for residents. Specifically, the cook did not check the temperature of breaded chicken before adding it to the steam table, and reheated meatballs were served without temperature verification. Additionally, potato salad was left out of refrigeration for nearly an hour without temperature checks, and its temperature was recorded at 55 degrees Fahrenheit, above the safe limit of 41 degrees Fahrenheit. The facility's policy required potentially hazardous cold foods to be kept at or below 41 degrees Fahrenheit and hot foods to be reheated to an internal temperature of 165 degrees Fahrenheit before service. However, there was no evidence that food temperatures were taken at the point of service or that cold food temperatures were monitored throughout the day. The Dietary Manager admitted that they had not been consistently checking food temperatures before service, relying instead on the assumption that the steam table and refrigerator were functioning correctly. The facility follows the Wisconsin Food Code, which allows food to be out of temperature control for up to four hours, provided it is initially at the correct temperature and marked to indicate the time it was removed from temperature control. However, the facility did not adhere to this standard, as there was no evidence of initial temperature checks or time markings. The Nursing Home Administrator acknowledged this oversight, noting that the facility's policy contradicted the Wisconsin Food Code by requiring food to be held at or below 41 degrees Fahrenheit without proper documentation or monitoring.
Failure to Ensure Proper Licensure for LPN
Penalty
Summary
The facility did not ensure that one of its Licensed Practical Nurses (LPN) had the proper licensure in accordance with Wisconsin state law. The surveyor reviewed the licensure information for 12 nurses and found that the facility did not have documentation of a Wisconsin license for one LPN. The facility provided documentation for a temporary licensure (ACT 10), but it had expired, and the LPN had not completed the nursing license application. The LPN had been working full-time at the facility without an active Wisconsin nursing license. The Department of Safety and Professional Services (DSPS) confirmed that the LPN had not completed the application for licensure. The Director of Nursing (DON) was informed of the findings and indicated that the LPN would be taken off the schedule. The DON assumed the application was in process based on an email from DSPS but did not follow up to confirm. The LPN also believed the application was in process but acknowledged that some items needed to be completed. The surveyor confirmed with DSPS that no application was being processed for the LPN's licensure.
Medication Administration Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for four residents. For Resident 1, multiple medications were not administered as per the physician's orders upon readmission. These included Flomax, Metoprolol Succinate, Lantus Solostar, Nystatin powder, Atorvastatin Calcium, Prednisone, Sertraline, Humalog KwikPen, and Entresto. The facility's documentation indicated confusion and delays in transcribing and administering these medications, leading to missed doses and incorrect administration. The Director of Nursing (DON) was unaware of several of these errors until informed by the surveyor. Resident 2 experienced a transcription error where Metoprolol Tartrate was incorrectly transcribed as Metoclopramide HCl, resulting in the resident receiving the wrong medication and missing three doses of the correct medication. There was no documentation of any side effects from the incorrect medication, and the DON was not aware of this error until the surveyor's interview. Resident 5 received Novolog insulin instead of the prescribed Insulin Lispro for eight days, twice a day, due to a mix-up in the medication cart. The facility did not order the correct insulin from the pharmacy, and the error was only identified after several doses had been administered. Resident 6 received an incorrect dosage of Lisinopril for 58 days due to a transcription error, where the order for 10mg was incorrectly transcribed as 20mg. The error was identified by nursing staff, and the physician was notified to clarify the correct dosage. The DON was not aware of this error until the surveyor's interview. Interviews with Licensed Practical Nurses (LPNs) revealed inconsistencies and confusion in the facility's process for entering and verifying physician orders. The DON acknowledged that the process did not always work as intended, leading to these medication errors. The facility's documentation and interviews indicated a lack of proper oversight and verification in the medication administration process, contributing to these deficiencies.
Failure to Assess Resident After Fall Incident
Penalty
Summary
The facility did not provide care and treatment in accordance with professional standards of practice related to resident assessment after a fall incident for one resident. The resident, identified as R7, reported a fall that occurred on 03/09/24, but the facility's licensed nursing staff did not assess R7 immediately after the fall was reported on 03/10/24. The only documentation related to the fall was the vital signs taken and pain medication given to R7 on 03/10/24. There was no documentation of an assessment or a fall report for the incident on 03/09/24. Subsequent assessments on 03/11/24 and 03/22/24 revealed a bruise and swelling on R7's left hip, but x-rays showed no fractures or acute osseous processes. Interviews with the facility staff, including LPNs and CNAs, indicated that the standard procedure for handling falls involves assessing the resident, notifying the physician and family, documenting the fall, and completing a fall report. However, this procedure was not followed in R7's case. The Director of Nursing (DON) was unaware of the lack of assessment and confirmed that the facility's process includes monitoring the resident post-fall. The deficiency was identified during a survey conducted on 05/14/24 and 05/15/24.
Failure to Assess and Supervise Resident's Nicotine Use
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible, specifically regarding the use of nicotine products. The facility lacked a policy for assessing residents who chose to smoke, and no smoking assessment or care plan was provided for a resident who used both cigarettes and chewing tobacco. The resident, who had a primary diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was observed smoking in the parking lot and had chewing tobacco within reach in their room. Despite the resident's nicotine patch being discontinued, no subsequent smoking assessment was completed as requested by the Director of Nursing (DON). The resident's most recent Minimum Data Set (MDS) indicated they had a Brief Interview for Mental Status (BIMS) score of 10, meaning they could be understood and understand others. Progress notes revealed that the resident often went out to smoke, and the nicotine patch order was discontinued without a follow-up smoking assessment. The facility failed to provide a care plan or smoking assessment to the surveyors at the time of the exit interview, indicating a lapse in ensuring the resident's safety and proper supervision regarding nicotine use.
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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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