Dove Healthcare - Superior
Inspection history, citations, penalties and survey trends for this long-term care facility in Superior, Wisconsin.
- Location
- 1800 New York Ave, Superior, Wisconsin 54880
- CMS Provider Number
- 525397
- Inspections on file
- 34
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Dove Healthcare - Superior during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in an incident where an LPN tapped or smacked the resident’s buttocks while the resident stood at the nurses’ station in a gown and brief, with her backside exposed. The resident verbally objected, and a CNA reported that the LPN repeated the action and laughed, causing the CNA discomfort. Although the facility’s abuse policy required immediate reporting of all alleged abuse to the State Agency, the DON did not report the allegation, concluding the LPN acted playfully and without intent to harm. The incident was not documented in the resident’s medical record as an incident, and no report was made to the State Agency, resulting in a failure to follow required abuse reporting procedures.
A resident with dementia and severe cognitive impairment was allegedly slapped or tapped on the buttocks by an LPN while standing at the nurses’ station in an open gown, after which the resident verbally objected and raised a fist. CNA interview notes documented that the LPN repeated the action and laughed, while the DON later described it as playful and without intent to harm. The facility failed to document the incident in the medical record, did not complete or document a physical, skin, or psychosocial assessment, did not ensure the investigation was reviewed by the Administrator or grievance officer, and did not report the allegation to the State agency as required by policy and law.
A CNA did not change contaminated gloves after emptying urine from a resident's catheter and continued to provide care, including cleansing, assisting with clothing, and handling personal items, before removing gloves and performing hand hygiene. The resident was on enhanced barrier precautions for a history of ESBL and had a suprapubic catheter. Facility policy and infection control expectations were not followed.
Multiple failures in infection prevention and control were observed, including the absence of a water management program, incomplete infection surveillance, improper implementation of transmission-based precautions, and poor staff practices such as inadequate hand hygiene, improper PPE disposal, and failure to disinfect shared equipment. Clean linens were transported and stored uncovered, and shared shower rooms contained used personal care items. A resident was provided with a wheelchair borrowed from another resident on contact precautions for C. diff, without proper disinfection. These deficiencies had the potential to affect all residents in the facility.
The facility failed to maintain a safe environment, leading to multiple deficiencies. A resident experienced repeated falls without proper interventions or documentation, and staff did not consistently use gait belts during transfers. Another resident was bathed without an emergency call system, and a third resident fell due to inadequate supervision despite being on direct 1:1 care. The absence of a call light in the bath house and lack of adherence to safety protocols were significant issues.
The facility failed to provide adequate nursing staff on the third floor, affecting 14 residents. Typically, one nurse and one CNA were responsible for 14-15 residents, with an additional CNA assigned to 1:1 care for a specific resident. This led to multiple falls and delayed care, including a resident left without assistance for 4 1/2 hours and another experiencing an unwitnessed fall. Staff and resident council concerns about inadequate staffing were not addressed, impacting resident well-being.
The facility did not ensure that a licensed pharmacist completed and documented monthly medication regimen reviews for multiple residents with complex medical and psychiatric needs. Medication orders often lacked clear indications, and there was no evidence of pharmacist review or physician follow-up, as confirmed by staff interviews and record review. This resulted in missing documentation for several months and a lack of compliance with facility policy.
Surveyors identified that snack/nourishment refrigerators on two floors were not consistently maintained according to professional standards, with some food items left uncovered and undated, and required internal thermometers missing from some units. Dietary staff relied on hand-held devices for temperature checks instead of permanent thermometers, contrary to FDA Food Code requirements. These issues had the potential to affect all residents on the affected floors.
A resident at high risk for falls was moved by a CNA from the floor to the bed without a prior assessment by a nurse, following a witnessed fall. The resident, who had conditions such as dementia and osteoporosis, hit her head during the fall and was later transferred to the hospital for evaluation. The facility's fall policy requires a nurse to assess residents before moving them after a fall, which was not followed in this case.
A resident with paralysis and skin integrity issues was not provided with a personal wheelchair, resulting in her remaining in bed continuously and being unable to attend activities. Staff confirmed the resident had to borrow another's wheelchair for appointments, and the Rehabilitation Director stated a wheelchair was shared between two residents, unaware of the resident's desire for her own. This failure did not align with facility policy to promote quality of life and equal access to care.
A resident with a history of trauma and intact cognition had a documented preference for female caregivers only, as noted in her care plan and staff Kardex. Despite this, a male CNA provided personal care to the resident, and staff interviews confirmed awareness of her preference. The facility did not consistently honor the resident's choice, resulting in a failure to support resident self-determination.
A resident with a history of urinary tract infections, septicemia, and an indwelling foley catheter was not provided with a comprehensive care plan addressing infection control measures specific to ESBL resistance. Despite ongoing antibiotic treatment and recent hospitalization, the care plan lacked targeted interventions for MDRO management, and staff did not implement transmission-based precautions.
A resident with severe cognitive impairment and incontinence, requiring substantial assistance for mobility and toileting, was left in a wheelchair for 4.5 hours without being repositioned or assisted with toileting, despite care plan instructions for checks every 2-3 hours. Staff interactions during this period did not include required ADL support, and staff confirmed the lapse in care.
A resident who was totally dependent on staff and at high risk for pressure injuries was not repositioned for over four hours and did not have a pressure-relieving cushion in their Broda chair, despite care plan and MDS documentation requiring these interventions. Staff interviews confirmed knowledge of repositioning protocols, but the expected care was not provided during the observed period.
A resident with limited mobility and multiple conditions affecting ROM did not receive the care planned to maintain mobility, as the prescribed walking program was not implemented or documented by staff. Observations showed the resident self-propelling in a wheelchair to meals, and both staff and the resident indicated the walking program was not consistently carried out or recorded, resulting in a deficiency.
A resident with a history of UTI, sepsis, and acute kidney failure had a Foley catheter removed per urology recommendation, but staff failed to monitor for post-void residual as required by policy. The bladder scanner was not working, and no alternative monitoring was performed until a large urine retention was discovered, leading to reinsertion of the catheter. Staff also did not clarify ambiguous orders or allow surveyors to observe catheter care procedures.
A resident with a history of respiratory issues was not consistently provided with safe and appropriate oxygen therapy as ordered. Staff failed to connect the resident to oxygen, did not monitor or document oxygen use and assessments as required, and did not implement a physician-ordered weaning schedule. There was also confusion among staff regarding responsibilities for checking and refilling portable oxygen tanks, and required documentation was incomplete.
A compounded narcotic medication prescribed for a resident was discontinued before use, but the medication remained in the medication cart beyond the required destruction timeframe. The DON confirmed the medication was never administered and described the destruction process, but the facility did not ensure the medication was removed and destroyed within 72 hours as required by regulation and policy.
Surveyors identified that temperature-sensitive medications, including insulin pens, vaccines, and oral suspensions, were stored in a medication room refrigerator that was consistently above the required temperature range. Staff were unclear about the process for checking and documenting refrigerator temperatures, and temperature logs were incomplete or missing for several days across multiple floors. These deficiencies resulted in improper storage of drugs and biologicals for several residents.
Surveyors found that two residents with severe cognitive impairment did not have documentation in their medical records to show they were offered, received, or declined influenza and pneumococcal vaccinations, as required by facility policy. Although assessments indicated the vaccines were offered and declined, no supporting evidence was present in the records, and no contraindications were documented.
A facility failed to timely report a resident-to-resident altercation where one resident grabbed another's wrist, leading to an emergency room visit for x-rays and bruising. The incident was not reported to the State Survey Agency or police immediately, as required by policy, and the investigation was delayed. Both residents involved had cognitive impairments and behavioral issues documented in their care plans.
A facility failed to investigate a resident-to-resident altercation promptly, where one resident grabbed another's wrist, leading to an emergency room visit. Despite immediate awareness, the facility delayed initiating an investigation, interviewing staff or residents, and implementing preventive measures. Both residents had significant cognitive impairments, with one having a history of behavioral disturbances.
The facility failed to maintain a clean and sanitary environment for food preparation, affecting all residents. Staff did not consistently monitor or document food temperatures, label opened food items, or test sanitizing solution concentrations. Incomplete refrigerator temperature logs and improper glove use were also observed, indicating non-compliance with food safety protocols.
A resident with dementia and a history of elopement risk was inadequately supervised, leading to an attempted elopement. The facility's door alarm system was found to be faulty during a survey, compromising resident safety. Staff intervention was required to redirect the resident back inside.
The facility did not adhere to physician orders for two residents requiring oxygen therapy, as their oxygen tubing was not changed weekly as prescribed. One resident's tubing was last changed on 9/26/24, and another's on 9/14/24, despite both having orders for weekly changes. The DON confirmed the requirement for weekly changes.
The facility failed to provide palatable food, as observed by surveyors and reported by residents. A test tray revealed a dry, hard, and bland pumpkin bar, while residents complained about meals being warm or rotten and lacking flavor. Concerns raised in resident council meetings went unaddressed, and the Dietary Manager did not conduct test trays to ensure food quality.
Failure to Report Alleged Physical Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to the State Agency as required by its own policy and by federal and state law. The facility’s abuse policy required that all alleged violations involving abuse be reported immediately, and no later than two hours after the allegation is made if the events involve abuse. A resident with vascular dementia, major depressive disorder, anxiety disorder, pain, and severe cognitive impairment (BIMS score 03/15) was involved in an incident where an LPN tapped or smacked the resident’s buttocks while the resident was at the nurses’ station wearing only a gown and brief, with her backside exposed toward the dining area. Documentation showed that when the nurse tied the gown and tapped the resident on the bottom, the resident said, “don’t do that, I don’t like that,” and, according to a CNA interview, the nurse smacked the resident’s brief a second time, prompting the resident to raise her fist and repeat that she did not like it. The incident occurred on or about 1/9/26, but review of the resident’s electronic medical record and incident reports revealed no documentation of the incident or any follow-up investigation in the resident’s chart, and the incident was not reported to the State Agency. The Executive Administrator acknowledged that this was an allegation of abuse that should have been reported immediately and was not. The DON, who investigated the incident, stated that she did not report it because she determined the LPN acted “in fun” and did not intend to hurt the resident. Interviews with the LPN and CNA corroborated that the LPN tapped or smacked the resident’s buttocks, that the resident verbally objected, and that the LPN repeated the action and laughed, making at least one CNA feel uncomfortable. Despite these facts and the facility’s written policy requiring immediate reporting of alleged abuse, the allegation was not reported to the State Agency.
Failure to Thoroughly Investigate and Report Alleged Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a thorough investigation of an allegation of physical abuse toward a resident and to ensure appropriate administrative review and reporting. Facility policy required that all abuse allegations be promptly and thoroughly investigated, with information collected to corroborate or disprove the incident and findings reviewed by the Administrator and grievance officer. A resident with vascular dementia, major depressive disorder, anxiety disorder, severe cognitive impairment (BIMS 03/15), and requiring assistance with ambulation was allegedly slapped or tapped on the buttocks by an LPN while at the nurses’ station wearing only a brief under a gown that was open toward the dining area. CNA interview documentation indicated the LPN smacked the resident’s brief, the resident stated, “I don’t like that,” the LPN did it again, and the resident raised a fist and repeated that she did not like it, while the LPN laughed. The DON later characterized the action as a playful tap done in fun and determined there was no intent to harm. Despite this allegation and the facility’s own policy, the investigation was incomplete and not properly escalated or reported. The resident’s electronic medical record contained no documentation of the incident or any follow-up investigation, and incident reports at admission did not include the alleged event. The facility did not perform or document a physical exam, skin assessment, or psychosocial assessment of the resident after the incident, and there was no indication that the investigation findings were reviewed by the Administrator or grievance officer. The Executive Administrator stated she was unaware of the allegation until informed by the surveyor, and confirmed the allegation had not been reported to the State Survey and Certification Agency as required by Federal and State law. The DON acknowledged that the incident was not reported externally because she concluded it was playful and without intent to harm.
Failure to Change Gloves and Maintain Infection Control During Resident Care
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to follow proper infection prevention and control procedures while providing care to a resident on enhanced barrier precautions due to a history of extended-spectrum beta-lactamase (ESBL) in the urine and the presence of a suprapubic catheter. The CNA donned personal protective equipment (PPE) before entering the resident's room and assisted the resident with toileting. During the process, the CNA emptied the resident's catheter into a graduate, disposed of a used brief on the bathroom floor instead of in the garbage, and placed the graduate on the floor. The CNA then continued to provide care, including cleansing the resident, pulling up the resident's pants, opening the bathroom door, assisting the resident to a wheelchair and bed, removing the resident's shoes, rearranging the bedside table, and placing the call light within reach—all while wearing the same contaminated gloves used during the initial catheter care. The CNA only removed the contaminated gloves and performed hand hygiene after completing all these tasks and before exiting the room. Upon interview, the CNA acknowledged not changing gloves after emptying the urine, contrary to facility policy and expected infection control practices. The Director of Nursing confirmed that the expectation is for staff to change gloves after such tasks and perform hand hygiene before continuing with other resident care activities.
Widespread Infection Control Failures and Lapses in Surveillance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in policy implementation and staff practices. The facility did not have a water management program in place to reduce the risk of Legionella and other waterborne pathogens, despite having policies that required such a program. Key staff, including the Environmental Services Director, were unaware of any water management program, and the facility was unable to provide documentation of system descriptions, hazard identification, or monitoring of control measures. A blank monitoring document was provided, but no active program was in place at the time of the survey. Infection surveillance was inadequately performed, with incomplete tracking and documentation of resident and staff infections. The line listing of infections lacked laboratory and diagnostic testing information, did not include all residents with infections or those prescribed antibiotics, and omitted necessary details such as criteria for infection and isolation precautions. Staff infection records were also incomplete, missing signs, symptoms, and return-to-work dates. The facility was unable to provide access to electronic surveillance records when requested by the surveyor. Transmission-based precautions were not consistently implemented for residents with known infections, such as those with multidrug-resistant organisms (MDROs) or Clostridium difficile. PPE disposal bins were improperly placed in hallways, with soiled PPE exposed, and staff did not always follow hand hygiene protocols or disinfect shared equipment between uses. Clean linens were transported and stored uncovered, sometimes in inappropriate locations such as shower rooms, and shared shower rooms contained used personal care items. In one instance, a resident requiring a bariatric wheelchair was provided with a chair borrowed from another resident on contact precautions for C. diff, and the cleaning process did not follow recommended disinfection protocols. Staff were observed failing to change gloves or perform hand hygiene during resident care, further contributing to the risk of infection transmission.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, affecting multiple residents. One resident, identified as R41, experienced multiple falls without the implementation of new interventions or proper documentation of neurological checks as per the facility's fall prevention policy. The staff did not consistently use gait belts during transfers, and there was a lack of adequate supervision and follow-up after falls. Additionally, the care plan interventions, such as placing a chair at the nurse's station for rest, were not observed to be implemented. Another resident, R57, was bathed without an emergency call system in place, and the staff failed to use a gait belt during transfers, leading to unsafe handling. The absence of a call light in the bath house posed a significant risk, as staff had to rely on shouting for help in emergencies. The maintenance department was unaware of the missing call light, and the issue had not been addressed for at least a month, affecting 21 residents on the second floor. Resident R58, with severe cognitive impairment and a history of falls, was not adequately supervised despite being on direct 1:1 supervision. The resident fell and hit her head while the assigned CNA was not within arm's length, as required by the care plan. The CNA moved the resident back to bed before a nurse could assess for injuries, contrary to the facility's fall policy. These deficiencies highlight a lack of adherence to safety protocols and inadequate staff training in handling residents at risk of falls.
Inadequate Staffing Leads to Resident Falls and Delayed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff on the third floor to meet the needs of all residents, which affected the well-being of 14 residents. The staffing pattern typically consisted of one nurse and one CNA for 14 to 15 residents, with an additional CNA assigned to 1:1 care for a specific resident, who was not available to assist others. This staffing level was inadequate to ensure timely response to residents' needs, as evidenced by multiple falls and delayed care. One resident, who was frequently incontinent and required assistance with mobility and toileting, was left without assistance for 4 1/2 hours, despite care plan instructions for toileting every 2-3 hours. Another resident experienced an unwitnessed fall and was not attended to until a surveyor intervened. Staff interviews confirmed that the staffing levels were consistently low, leading to delayed responses to call lights and increased risk of falls. The Director of Nursing was informed of the staffing issues and the impact on resident care, including the falls and delayed assistance. Despite staff and resident council concerns about inadequate staffing, no additional help was routinely provided, and the facility did not adjust staffing levels to prevent falls and ensure timely care for residents.
Failure to Complete and Document Monthly Pharmacist Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews for all residents sampled, as required by facility policy. For five residents with complex medical and psychiatric conditions, there was no evidence in the medical records that a pharmacist had completed monthly reviews or that any recommendations were communicated to or acknowledged by physicians. The facility's own policies require monthly pharmacist review and documentation of findings, as well as reporting of any irregularities to the attending physician, medical director, and director of nursing. Specific examples included residents with diagnoses such as major depressive disorder, schizophrenia, diabetes, dementia, and anxiety, who were prescribed multiple medications, including psychotropics and insulin. In several cases, medication orders lacked clear indications for use, and there was no documentation of pharmacist review or follow-up on recommendations. Interviews with the DON and NHA confirmed the absence of a system to monitor monthly pharmacy reviews and the lack of accessible documentation, with the DON unable to provide any pharmacy review records beyond locked email attachments that could not be opened. Record reviews for additional residents revealed missing pharmacy reviews and signatures for multiple months, indicating a pattern of non-compliance with the requirement for consistent monthly medication regimen reviews. Care plans for some residents referenced the need for pharmacy consultation and medication review, but the corresponding documentation was not present in the records. The deficiency was identified through both record review and staff interviews, confirming that the facility did not maintain required documentation or ensure completion of monthly pharmacist reviews.
Improper Food Storage and Temperature Monitoring in Unit Refrigerators
Penalty
Summary
Surveyors found that the facility failed to maintain proper food storage practices in the snack/nourishment refrigerators on both the first and third floors. Observations revealed that some food items, such as an opened bottle of salad dressing and an uncovered cup of liquid, were not labeled with the date opened or a use-by date, and the cup was not covered. Staff interviews confirmed that dietary staff were responsible for ensuring food and beverage items were labeled and stored correctly, but these procedures were not consistently followed. Additionally, temperature logs for the refrigerators and freezers were completed and showed temperatures within acceptable limits, but there were missing internal thermometers in some units, and staff were using hand-held devices to check temperatures instead. Further review with the Dietary Manager confirmed that dietary staff should have identified and removed undated and uncovered food items during their morning checks. The use of hand-held devices to measure ambient temperatures was also discussed, and it was clarified that this practice does not align with the US FDA Food Code, which requires a permanent temperature measuring device in each unit. These lapses in food storage and temperature monitoring practices have the potential to affect all residents on the first and third floors.
Failure to Follow Fall Assessment Protocols
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan. A resident, identified as R58, who was at high risk for falls due to conditions such as unspecified dementia, Alzheimer's disease, and osteoporosis, experienced a witnessed fall. Despite the resident's high fall risk, a Certified Nursing Assistant (CNA) transferred the resident from the floor to the bed before a Registered Nurse could assess the resident for injuries. This action was contrary to the facility's fall policy and procedure, which requires a nurse to assess residents before moving them after a fall. The incident occurred when a Licensed Practical Nurse (LPN) heard a thump and a voice swearing, indicating a fall had occurred. Upon entering the room, the LPN found the resident in bed, suggesting that the CNA had moved the resident without a prior assessment by a nurse. The Director of Nursing (DON) confirmed that the CNA transferred the resident to bed before calling for help, which was not acceptable practice. The resident was subsequently transferred to the hospital for evaluation after hitting her head during the fall.
Failure to Provide Wheelchair Limits Resident Mobility and Participation
Penalty
Summary
A deficiency was identified when a resident with left-sided paralysis, stage 1 pressure ulcers, morbid obesity, and mental health diagnoses was not provided with a wheelchair to facilitate mobility and participation in facility activities. The resident, who was cognitively intact and dependent on staff for activities of daily living, reported being confined to bed 24 hours a day due to the lack of a suitable wheelchair. Although the care plan included interventions related to wheelchair use and therapy evaluation for wheelchair positioning, the resident stated she only used a new wheelchair once as it did not fit, and subsequently had to borrow another resident's wheelchair for appointments. She expressed increased feelings of depression and inability to attend activities due to this limitation. Staff interviews confirmed awareness of the resident's lack of a personal wheelchair. A CNA acknowledged that the resident borrowed another's wheelchair for appointments and otherwise remained in bed, and felt the resident should have her own wheelchair. The Rehabilitation Director stated that a wheelchair was shared between the resident and another individual, based on the assumption that neither used it frequently, and was unaware that the resident desired her own wheelchair. The facility's policy requires care to be provided in a manner that promotes quality of life and equal access to services, which was not met in this instance.
Failure to Honor Resident's Gender Preference for Caregivers
Penalty
Summary
The facility failed to honor a resident's right to self-determination and support of resident choice by not consistently providing only female caregivers for personal care, as specified in the resident's care plan. The resident, who has a history of rape and diagnoses including depression, dementia, mood disturbance, and anxiety, had a documented preference for female caregivers only, which was noted in her care plan and on the staff Kardex. Despite this, the resident reported that a male caregiver assisted her with a shower and morning cares, which she did not want. Staff interviews confirmed awareness of the resident's preference, and documentation showed the facility had identified and care planned for this preference months prior. Review of staff schedules and interviews revealed that a male CNA provided personal care to the resident on a specific date, and he did so alone due to scheduling conflicts. The CNA did not recall the resident as one who required female caregivers or care in pairs, despite this being documented. The DON acknowledged the care plan directive but stated the resident sometimes changed her mind about caregiver gender, though the care plan clearly indicated the resident's preference for female caregivers only. The facility's actions did not align with the resident's documented wishes, resulting in a failure to promote and facilitate resident self-determination.
Failure to Develop and Implement ESBL-Specific Infection Control Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing the medical and nursing needs of a resident with Extended Spectrum Beta Lactamase (ESBL) resistance, a type of multidrug-resistant organism (MDRO). The resident, who had a history of urinary tract infections, septicemia, and an indwelling foley catheter, was admitted with ESBL resistance and had been hospitalized for septicemia related to a UTI. Despite these conditions, the care plan did not include specific interventions for controlling and preventing the spread of infection related to ESBL resistance, as required by facility policy and best practices for MDRO management. Observations and interviews revealed that the resident was not placed on transmission-based precautions, and staff, including an LPN and the Director of Nursing, were aware of the resident's recent hospitalization and ongoing antibiotic treatment for ESBL. However, the care plan only addressed general precautions related to the foley catheter and impaired immunity, without addressing the specific infection control needs for ESBL resistance. The lack of a targeted care plan for ESBL was confirmed by record review and staff interviews, with no additional information or interventions provided to address the resident's MDRO status.
Failure to Provide Timely Repositioning and Toileting Assistance
Penalty
Summary
A resident with chronic kidney disease, vascular dementia, urinary incontinence, leg pain, and osteoarthritis, who was assessed as requiring substantial or maximal assistance for all mobility and toileting, did not receive timely care for activities of daily living. The resident's care plan specified assistance with toileting every 2-3 hours and as needed, as well as regular checks and changes for incontinence. Despite these interventions, the resident was observed sitting in a wheelchair in the dining area for 4.5 hours without being repositioned, checked for incontinence, or assisted to the bathroom. During this period, staff interacted with the resident by offering food, drinks, and reading material, but did not provide the required assistance with toileting or repositioning. Staff interviews confirmed that the resident had not been repositioned or toileted since being brought to the dining room that morning, exceeding the care plan's specified frequency. The Director of Nursing acknowledged that the expectation was for such residents to be assisted every 2-3 hours, which was not met in this instance.
Failure to Reposition High-Risk Resident and Provide Pressure-Relieving Device
Penalty
Summary
A resident with diagnoses including severe vascular dementia, Alzheimer's disease, hemiplegia, and major depressive disorder was identified as being at high risk for pressure injuries, as indicated by repeated low Braden scale scores and care plan documentation. The resident was totally dependent on staff for all care and required a pressure-relieving device in their chair, as well as regular repositioning to prevent skin breakdown. Despite these documented needs, the resident was observed in a Broda chair without a pressure-relieving cushion and was not repositioned for over four hours during the surveyor's continuous observation period. Staff interviews revealed that both the CNA and TMA were aware of the expectation to reposition dependent residents every 2-3 hours, yet the CNA believed that transferring the resident to bed and back for incontinence care was sufficient repositioning, even though the resident remained on their back throughout. The Director of Nursing confirmed that the resident should have been repositioned within the expected timeframe and that a pressure-relieving cushion should have been present in the chair, as indicated in the resident's care plan and MDS documentation.
Failure to Implement and Document Resident Walking Program
Penalty
Summary
A deficiency occurred when a resident with limited mobility and multiple diagnoses affecting range of motion, including osteoporosis, fractures, and a history of falls, did not receive the care planned to maintain or prevent further reduction in mobility. The resident's care plan included a walking program, specifying ambulation to and from all meals with the assistance of one staff member, using a front-wheeled walker and gait belt, as recommended by therapy. However, observations over several days showed the resident self-propelling in a wheelchair to meals without staff assistance or implementation of the walking program. The resident reported not being aware of any walking intervention, and staff interviews revealed inconsistent understanding and execution of the walking program. Record review found no documentation of the walking program being carried out, no progress notes, and no CNA charting to indicate the intervention was implemented or refused. The Director of Nursing and Rehabilitation Director both confirmed that staff were expected to follow the walking program and document interventions or refusals, but acknowledged that there was no evidence of such documentation. The lack of implementation and documentation of the walking program, as outlined in the resident's care plan and facility policy, led to the deficiency.
Failure to Monitor and Provide Appropriate Care After Foley Catheter Removal
Penalty
Summary
The facility failed to ensure that a resident with an indwelling Foley catheter received care and treatment consistent with professional standards to prevent complications or urinary tract infections. Urology recommended removal of the Foley catheter when the resident regained strength, and the facility removed the catheter the following day. However, after removal, no monitoring was performed as required by facility policy, which includes assessing for post-void residual (PVR) and documenting the procedure. The primary provider attempted to use a bladder scanner to check PVR, but the scanner was not working, and no alternative monitoring was completed until catheterization for residual was performed, resulting in a significant urine return and necessitating reinsertion of the Foley catheter. The resident had a complex medical history, including recent hospitalization for urinary tract infection, sepsis, and acute kidney failure, and was receiving active infection treatment upon return to the facility. The care plan identified the risk of complications related to the Foley catheter, but staff did not clarify ambiguous orders regarding catheter removal and failed to follow monitoring protocols after removal. Additionally, surveyors noted that staff did not allow observation of catheter care procedures during the survey period. These actions and inactions led to a deficiency in providing appropriate catheter care and monitoring to prevent urinary tract complications.
Failure to Provide Safe and Consistent Respiratory Care for Resident on Oxygen
Penalty
Summary
A resident with a history of quadriplegia, intracranial injury, and emphysema was readmitted to the facility following hospitalization for acute respiratory failure and was prescribed oxygen therapy. The facility failed to develop a respiratory care plan addressing the resident's oxygen use, and did not document required respiratory assessments or implement a physician-ordered weaning schedule. Physician orders specified oxygen at 2 liters per minute to maintain oxygen saturation above 90%, with daily and weekly monitoring, and instructions to wean oxygen as able, but these were not consistently followed or documented. On multiple occasions, staff did not ensure the resident received continuous oxygen as ordered. A CNA failed to connect the resident to a portable oxygen tank when transferring the resident to the dining room, and later admitted forgetting to apply the oxygen tubing. Additionally, the resident was observed with an empty oxygen tank, and staff were unclear about responsibilities for checking and refilling portable tanks. Documentation logs for oxygen tank changes were incomplete, and staff did not consistently sign out filled tanks as required by facility policy. Interviews with staff and the Director of Nursing revealed a lack of clear procedures for monitoring oxygen tank levels, refilling tanks, and implementing the physician's weaning orders. The facility's own policy required documentation of assessments and care planning for oxygen therapy, but these were not in place or followed. The provider later questioned the ongoing need for oxygen therapy, indicating a lack of communication and follow-through on discharge instructions.
Failure to Timely Destroy Discontinued Controlled Medication
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with state regulations and its own policies regarding the timely destruction of controlled medications. Specifically, a compounded narcotic medication (ABH gel) prescribed for a resident was discontinued before administration, but the medication remained stored in the medication cart beyond the required 72-hour destruction window. Observation by the surveyor revealed that the medication, consisting of multiple unlabeled fluid-filled syringes in a Ziploc bag, was not removed from storage or destroyed as mandated by both state statute and facility policy. Interviews with the Director of Nursing (DON) confirmed that the medication was never administered and was discontinued due to its classification as a chemical restraint. The DON described the facility's destruction process, which involves two staff members reconciling and disposing of medications, but did not specify a timeframe for destruction. The failure to remove and destroy the discontinued medication within the required period constituted noncompliance with both regulatory and internal policy requirements.
Failure to Properly Store Temperature-Sensitive Medications and Maintain Temperature Logs
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were stored according to accepted professional standards. Specifically, seven unopened insulin pens, one unopened injectable solution, one unopened vaccine, and one unopened oral suspension—each requiring refrigeration—were discovered in a second-floor medication room refrigerator that was out of the required temperature range. The thermometer in this refrigerator consistently read between 48-50°F, exceeding the acceptable range of 36-46°F. Additionally, the process for checking and documenting refrigerator temperatures was unclear to staff, and temperature logs for the refrigerator were incomplete, with several days missing entries over the past six months. Further review revealed that temperature-sensitive medications belonging to multiple residents were stored in this refrigerator, and similar documentation issues were present on other floors. The facility's policy and state guidelines require daily temperature checks and documentation, but these were not consistently performed. Interviews with staff confirmed gaps in knowledge and adherence to procedures for monitoring and recording refrigerator temperatures, as well as uncertainty about the process for addressing out-of-range readings.
Lack of Documentation for Flu and Pneumonia Vaccinations
Penalty
Summary
Surveyors identified that the facility failed to maintain proper documentation regarding the offering and administration of influenza and pneumococcal vaccinations for two out of five residents reviewed. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and Alzheimer's disease, the Minimum Data Set (MDS) assessment indicated the resident was offered and declined the pneumococcal vaccine. However, the resident's medical record did not contain any evidence that the vaccine was offered, received, declined, or that there was a contraindication. Despite requests, no additional documentation was provided to support that the required process was followed. Similarly, another resident with severe cognitive impairment and multiple mental health diagnoses had an MDS assessment indicating that both influenza and pneumococcal vaccines were offered and declined. Upon review, the medical record lacked documentation to confirm that the vaccines were offered, received, declined, or that there was a contraindication. The facility's policies require that all residents be offered these immunizations annually, with documentation of administration, refusal, or contraindication, but this was not reflected in the records for these two residents.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation in a timely manner as required by their policy. The incident involved a resident, R5, who grabbed the wrist of another resident, R4, resulting in R4 being transferred to the emergency room for x-rays and developing bruising on the wrist. The facility did not report the incident to the State Survey Agency or the police department immediately upon learning of it, as required by their policy, which mandates reporting within two hours if serious bodily injury is suspected, or within 24 hours otherwise. The incident was not reported until four days later, and the completed investigation was not submitted until ten days after the incident. R4, who was admitted to the facility with Alzheimer's and vascular dementia, has documented short-term and long-term memory problems and is severely impaired in decision-making. R4's care plan notes alterations in mood and behavior, with potential aggression towards others. R5, admitted with a traumatic subdural hemorrhage, Alzheimer's, and delusional disorder, also has memory problems and is rarely understood. R5's care plan indicates behavioral disturbances and anger outbursts. Despite the facility being aware of the incident immediately, the Assistant Nursing Home Administrator confirmed that the incident was not reported in accordance with the facility's policy.
Failure to Investigate Resident Altercation
Penalty
Summary
The facility failed to conduct an investigation following a resident-to-resident altercation that occurred on October 5, 2024. During this incident, one resident grabbed another resident's wrist, leading to the latter being transferred to the emergency room for x-rays due to bruising. Despite being aware of the incident immediately, the facility did not initiate an investigation, interview staff or residents, or implement interventions and monitoring to prevent recurrence until October 9, 2024. This delay in response was contrary to the facility's policy on reporting and responding to alleged violations related to mistreatment, neglect, or abuse. The residents involved had significant cognitive impairments. The resident who was grabbed had Alzheimer's and vascular dementia, with severe impairments in decision-making and memory. The resident who grabbed the wrist had a history of traumatic subdural hemorrhage, Alzheimer's, and delusional disorder, with behavioral disturbances and anger outbursts noted in their care plan. The facility's failure to promptly address the incident and adhere to its policy potentially affected the safety and well-being of the residents involved.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the preparation of food in a clean and sanitary environment, potentially affecting all 71 residents. Staff did not consistently monitor or document cooked food temperatures, as evidenced by missing temperature logs on multiple dates in August, September, and October. Additionally, staff failed to date or label food items when opened, with several open containers found without labels indicating when they were opened. The Dietary Manager confirmed that the facility relied on the manufacturer's expiration date and only labeled gallon jugs, which was not consistently followed. Furthermore, the facility did not consistently test or document the parts per million (PPM) of the quaternary sanitizing solution, with missing entries on the sanitizer log for specific dates. Refrigerator temperature logs were also incomplete, with missing documentation for the produce and milk logs. Additionally, a staff member was observed touching ready-to-eat food with contaminated gloves after adjusting their clothing, which was acknowledged by the Dietary Manager as inappropriate behavior. These deficiencies indicate a lack of adherence to food safety protocols and documentation requirements.
Inadequate Supervision and Faulty Door Alarm for Elopement Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified as having a potential for wandering and elopement. The resident, who was admitted with a diagnosis of dementia and other cognitive impairments, had a history of leaving the facility without informing staff. Despite being the only resident on the first floor identified as an elopement risk, the facility did not provide sufficient supervision or ensure that safety measures, such as functioning door alarms, were in place to prevent potential elopement. During an incident, the resident attempted to leave the facility, triggering the wander guard alarm. Although staff intervened and redirected the resident back inside, a subsequent survey revealed that a door alarm near the resident's room was not functioning. This malfunction was discovered when a surveyor, accompanied by an LPN, tested the door alarm system, which failed to sound. The LPN acknowledged the issue and indicated that a maintenance call would be made to repair the alarm. This deficiency highlights a lapse in the facility's adherence to its policy on preventing elopement and ensuring resident safety.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents who required oxygen therapy. Resident 2, diagnosed with emphysema, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, was observed using oxygen tubing that had not been changed since 9/26/24, despite physician orders to change it weekly. Similarly, Resident 7, who has a history of pneumonia and other respiratory conditions, was using oxygen tubing dated 9/14/24, also contrary to the weekly change order. These observations were made on 10/08/24 and 10/09/24, and the Director of Nursing confirmed that oxygen cannulas should be changed weekly.
Facility Fails to Provide Palatable Food
Penalty
Summary
The facility failed to provide palatable food to its residents, as evidenced by observations and interviews conducted by surveyors. Three residents expressed concerns about the quality of their meals. A test tray sampled by a surveyor revealed that a pumpkin bar served was dry, hard, and bland, making it difficult to cut with a fork. One resident commented on the bar's hardness, warning another resident about the risk of breaking a tooth. Another resident reported that breakfast was often either warm or rotten. A third resident mentioned that concerns about the food quality were repeatedly raised during resident council meetings without any improvements. This resident also described a meal of plain egg noodles with hamburger and no sauce, noting that a significant portion of the food was discarded due to poor taste. The Dietary Manager admitted to not performing test trays to ensure food palatability.
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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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