East Troy Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in East Troy, Wisconsin.
- Location
- 3271 North St, East Troy, Wisconsin 53120
- CMS Provider Number
- 525561
- Inspections on file
- 20
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at East Troy Manor during CMS and state inspections, most recent first.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents. The environment contained risks that were not properly addressed, and oversight was insufficient to ensure resident safety.
Six direct care staff, including an LPN and several CNAs, did not receive required training on effective communication, as confirmed by missing documentation and staff interviews. This deficiency was identified during a review of staff records and acknowledged by facility leadership, potentially impacting all residents due to lack of staff competency in communication.
Four staff members, including a dietary aide and three CNAs, did not receive required training on resident rights and responsibilities as mandated by facility policy. Review of employee records revealed missing documentation of this training, and the NHA confirmed that no further evidence of completed training was available.
Four CNAs did not receive required training on abuse prevention, reporting procedures, and dementia management, as confirmed by a review of employee records and staff interviews. The facility's policy mandates this training for all staff, but documentation was lacking, and the NHA acknowledged the deficiency. This lapse had the potential to impact all residents in the facility.
Four staff members, including CNAs and a Dietary Aide, did not receive mandatory QAPI training as required by facility policy. Review of employee records revealed missing documentation of completed training, and the NHA confirmed no further records were available. This deficiency had the potential to impact all residents in the facility.
Four staff members, including CNAs and a Dietary Aide, did not receive mandatory infection prevention and control training as required by facility policy. The facility could not provide documentation of completed training for these staff, and the NHA confirmed the lack of records. This deficiency had the potential to impact all residents.
Five staff members, including CNAs and a Dietary Aide, did not receive required compliance and ethics training as mandated by facility policy. The facility was unable to provide documentation of completed training for these staff, and the NHA confirmed the absence of records. This deficiency had the potential to impact all residents in the facility.
Five CNAs did not complete the required 12 hours of annual inservice education, as shown by a lack of documentation in their employee records. The facility's policy mandates regular inservice training on key topics such as abuse prevention, dementia care, and infection control, but the staff development coordinator did not document completion for these CNAs. The NHA confirmed the absence of records, and the deficiency had the potential to impact all residents.
The facility did not ensure that all staff, including nursing, housekeeping, and dietary personnel, received required behavioral health training as mandated by facility policy. Documentation verifying completion of this training was not available for eight randomly selected staff members, and the NHA confirmed the absence of records. This deficiency had the potential to impact all residents in the facility.
The facility did not consistently document and post the actual daily nursing staff hours for each category as required, with several days missing this information. Staff interviews confirmed that postings were not updated in real time to reflect actual hours worked, and the required information was often completed after the fact or left blank.
The facility did not maintain an effective QAPI program, failing to systematically track and trend falls as required by policy. Despite documentation showing 37 falls over six months, the DON did not consistently analyze or report this data, and the Administrator confirmed that falls were not being properly tracked or discussed in QAPI meetings.
The facility did not ensure that agency CNAs received adequate training or communication regarding resident care requirements, as evidenced by incomplete documentation of training, agency staff unfamiliarity with care cards, and inconsistent adherence to care protocols for resident transfers. Facility staff acknowledged that the current system was ineffective, and some resident falls were linked to staff not following care cards.
Staff did not follow established transfer protocols for a resident with significant mobility and medical needs, using improper equipment and insufficient staff assistance during transfers. This led to two separate falls, as the resident was transferred with only one staff member and, in one instance, with the wrong type of lift, despite clear care plan instructions and facility policy requiring two-person assistance with a Sara Steady.
A resident with multiple health conditions experienced a significant change in condition, including difficulty with transfers and eating, but the RN on duty failed to perform a comprehensive assessment or notify the physician. The resident later became unresponsive and was diagnosed with severe sepsis at the hospital, where they subsequently expired. The facility's failure to follow protocol resulted in a finding of immediate jeopardy.
A resident identified as a wander/elopement risk due to dementia was not provided adequate supervision and assistance devices, leading to two elopement incidents. The facility placed the resident's Wanderguard on the wheelchair instead of the resident, despite the resident's ability to ambulate independently. This failure to adhere to policies and procedures resulted in the resident being found outside the facility on two occasions, creating a reasonable likelihood for serious harm.
The facility did not thoroughly investigate four infectious outbreaks, including COVID-19, norovirus, and influenza, between August 2023 and January 2024. Documentation was limited to line lists and training records, with no investigation into the outbreaks' sources. The IP-C was unaware of the need for documented investigations.
The facility failed to provide required transfer or discharge notices to four residents, as identified during a survey. The Nursing Home Administrator admitted that no transfer notices were issued, and the facility's policy was not followed. This deficiency was confirmed through interviews and record reviews.
A resident with cognitive intactness was found with bruising on her thigh and knee, but the LTC facility failed to report this injury of unknown origin to the state survey agency within the required timeframe. The NHA and DON were unaware of the incident due to a lapse in communication, and the investigation was initiated late. The facility did not submit the investigation findings within the mandated period, violating their policy.
A resident with cognitive intactness but physical dependency was found with unexplained bruising on her inner thigh and knee, areas not prone to trauma. The facility did not investigate or report the injury as required by their policy. The NHA only began investigating after being informed by surveyors, citing a lack of communication as the reason for the delay.
The facility failed to provide written bed hold notices to residents during hospital transfers, as required by policy. Three residents did not receive documentation about the bed hold policy, reserve bed payment, and their right to return. The Nursing Home Administrator admitted that no one was responsible for issuing these notices, leading to non-compliance with the facility's policy.
A facility failed to develop a comprehensive care plan for a resident with an indwelling catheter, despite the resident's diagnosis of neurogenic bladder and history of failed voiding trials. The resident's electronic medical record lacked documentation of a care plan addressing the catheter's long-term use and the resident's occasional refusals of care. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged that a care plan should have been completed and updated.
A resident received medications that were not properly labeled or dated during a medication pass. The LPN confirmed that the vitamins were purchased by the resident and lacked necessary labeling and expiration information. The facility's policy requires medications brought in by residents to be reported and dated, but this was not followed. The DON acknowledged the issue but could not explain why the medications were administered without proper labeling.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight to mitigate these risks. The report specifically notes the lack of preventive measures and supervision in the area, which directly contributed to the potential for accidents among residents. No further details about individual residents or their medical conditions are provided in the report.
Failure to Provide Required Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that six randomly selected direct care staff members, including an LPN and five CNAs, received the required training on effective communication as outlined in the facility's in-service training policy. The policy mandates that all staff, including new and existing personnel, must participate in initial orientation and annual in-service training, with effective communication being a required topic for direct care staff. During the survey, the facility was unable to provide documentation verifying that these staff members had completed the necessary training on effective communication. Interviews with the Nursing Home Administrator (NHA) confirmed the absence of documentation for the required training and acknowledged the ongoing issue with staff education. The NHA indicated that there was no further documentation available for the selected staff and recognized the need for a designated training coordinator. This lack of documented training had the potential to affect all 39 residents in the facility, as staff competency in effective communication is essential for quality resident care.
Failure to Provide Required Resident Rights Training to Staff
Penalty
Summary
The facility failed to ensure that four randomly selected staff members, including a dietary aide and three certified nursing assistants, received the required training on resident rights and responsibilities. According to the facility's own policy, all staff must participate in initial orientation and annual in-service training, including specific topics such as resident rights and responsibilities. Documentation of completed training, including date, topic, method, and competency assessment, is required to be maintained by the staff development coordinator or designee. During the survey, the surveyor reviewed employee records for the selected staff and found no documentation verifying that they had received the required training. When questioned, the Nursing Home Administrator acknowledged the lack of documentation and stated that there was no further evidence of completed training for these staff members. The deficiency was confirmed during interviews with the administrator and the Director of Nursing, who both recognized the issue with staff education and training documentation.
Failure to Provide Required Staff Training on Abuse Prevention and Dementia Care
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs), selected at random, received the required training on abuse prevention, activities that constitute abuse, procedures for reporting abuse, and dementia management. Review of employee records for these CNAs revealed that there was no documentation verifying completion of the mandated training. The facility's policy requires all staff, including new and existing personnel, contract workers, and volunteers, to participate in initial orientation and annual in-service training on these topics, with documentation maintained by the staff development coordinator or designee. During the survey, the Nursing Home Administrator (NHA) acknowledged the lack of documentation for the required trainings and indicated that there was no further evidence available to demonstrate compliance. The NHA also stated that education is a problem within the facility and mentioned considering the designation of a training coordinator. This deficiency had the potential to affect all 39 residents in the facility, as staff may not have been adequately prepared to prevent, identify, or report abuse, neglect, or exploitation, or to manage residents with dementia.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that four randomly selected staff members, including three Certified Nursing Assistants and one Dietary Aide, received the required training on the Quality Assurance and Performance Improvement (QAPI) program. According to the facility's policy, all staff must participate in initial orientation and annual in-service training, which includes QAPI as a required topic. The policy also mandates that training be completed prior to staff providing services to residents, and that documentation of completed training be maintained by the staff development coordinator or designee. During the survey, the surveyor reviewed employee records for the selected staff and found no documentation verifying completion of the required QAPI training. The Nursing Home Administrator confirmed that there was no further documentation available for these staff members and acknowledged ongoing issues with staff education. The lack of required QAPI training had the potential to affect all 39 residents in the facility.
Failure to Provide Required Infection Prevention and Control Training to Staff
Penalty
Summary
The facility failed to ensure that four randomly selected staff members, including three Certified Nursing Assistants (CNAs) and one Dietary Aide, received the required training on infection prevention and control as mandated by the facility's own policies. The policy specifies that all staff must participate in initial orientation and annual in-service training, including infection prevention and control standards, prior to providing services to residents and annually thereafter. During a review of employee records, the surveyor was unable to find documentation verifying that these staff members had completed the required training. When questioned, the Nursing Home Administrator (NHA) acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The NHA also indicated that education was a problem within the facility and mentioned considering the designation of a training coordinator. The absence of documented infection prevention and control training for these staff members had the potential to affect all 39 residents in the facility.
Failure to Provide Required Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to ensure that five randomly selected staff members, including four Certified Nursing Assistants (CNAs) and one Dietary Aide, received the required training on compliance and ethics. According to the facility's own policy, all staff are mandated to participate in initial orientation and annual in-service training, which must include compliance and ethics program standards, policies, and procedures. The surveyor's review of employee records revealed that there was no documentation verifying that these staff members had completed the required compliance and ethics training. During interviews, the Nursing Home Administrator (NHA) acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The NHA also indicated that education is a problem within the facility and mentioned considering the designation of a training coordinator. The deficiency was identified as having the potential to affect all 39 residents in the facility, as staff training is essential for ensuring quality of care and compliance with facility policies.
Failure to Ensure Required Annual Inservice Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) completed the required 12 hours of annual inservice education training, as mandated by facility policy and federal regulations. During a survey, a review of employee records for five randomly selected CNAs revealed that none had documentation verifying completion of the required inservice hours for their respective annual periods based on their hire dates. The facility's policy specifies that all staff must participate in regular inservice education, including training on topics such as effective communication, resident rights, abuse prevention, dementia care, infection control, and behavioral health. However, the staff development coordinator or designee did not document the completion of these trainings for the selected CNAs. The facility assessment did not include details regarding the requirement for CNAs to receive a minimum of 12 hours of training per year. When interviewed, the Nursing Home Administrator acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The deficiency had the potential to affect all 39 residents residing in the facility, as the CNAs may not have been adequately trained in essential care and safety topics.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received the required behavioral health training as outlined in its own policy and procedure. During a review of employee records for eight randomly selected staff members, including nursing, housekeeping, and dietary personnel, the facility was unable to provide documentation verifying completion of behavioral health training for any of these individuals. The policy requires all staff, including new hires and existing personnel, to participate in initial orientation and annual in-service training on behavioral health, with documentation maintained by the staff development coordinator or designee. Interviews with the Nursing Home Administrator (NHA) confirmed that there was no further documentation available to verify that the required training had been completed for the selected staff. The NHA acknowledged the lack of documentation and indicated that education was a problem within the facility. This deficiency had the potential to affect all 39 residents in the facility, as staff may not have been adequately prepared to address behavioral health needs as required by facility policy and federal regulations.
Failure to Accurately Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings included all required and accurate information, specifically the total nursing staff hours for each category. According to the facility's policy, the number of licensed and unlicensed nursing personnel, their actual hours worked, and other staffing details must be posted within two hours of each shift's start. However, a review of daily postings over a two-week period revealed that several dates were missing the required documentation of total nursing staff hours. On the day of survey, the posting also lacked this information. Interviews with the scheduler and the nursing home administrator confirmed that the postings were not consistently updated to reflect actual hours worked, especially when changes occurred during the day. The scheduler stated that hours were often completed the next morning and not adjusted in real time, and acknowledged that missing information indicated the task was not done. The administrator confirmed the expectation that actual working hours should be documented daily and adjusted as needed, but observed that this was not occurring. No further information was provided by the facility regarding the missing documentation.
Failure to Track and Trend Falls in QAPI Program
Penalty
Summary
The facility failed to establish and maintain an effective Quality Assurance and Performance Improvement (QAPI) program as required by its own policy and regulatory standards. Specifically, the QAPI program did not adequately track and trend falls, which is a key indicator of resident safety and quality of care. Although the facility's policy outlined a systematic approach to identifying, analyzing, and correcting quality deficiencies, including tracking and measuring performance, the actual practice did not align with these requirements. The Director of Nursing (DON) admitted to not consistently tracking or trending falls, stating she did not perceive a pattern, and did not always prepare or distribute fall reports for QAPI meetings as expected. The Administrator confirmed that the DON was not fulfilling the responsibility to track and trend falls, which should have been a significant focus of the QAPI meetings. Facility documentation showed that there were 37 falls over a six-month period, but this data was not systematically analyzed or used to identify trends or underlying causes. The DON's review of falls was limited to certain factors, such as time of day and associated illnesses, and did not include other potential contributing factors like days of the week. The lack of structured, data-driven investigation and analysis meant that the facility did not fully utilize available information to improve resident safety and quality of care, as required by its QAPI policy.
Deficient Training and Communication for Agency Staff on Resident Care Requirements
Penalty
Summary
The facility failed to establish an effective training and communication system for contracted agency staff regarding the level of care required by residents. Agency CNAs were expected to review resident care information in a binder and use care cards located in residents' closets to determine transfer needs. However, documentation showed that not all agency CNAs had signed off on having reviewed this information. Interviews with agency CNAs revealed that some did not recall signing any forms or receiving adequate training upon starting at the facility, and one CNA stated that it was difficult to know how to care for residents due to insufficient information provided by the facility. Further interviews with facility staff, including an LPN and the DON, confirmed that staff were expected to follow care cards for resident transfers, but this was not consistently done. The DON acknowledged that staff did not always adhere to the care cards, as evidenced by some resident falls. The Administrator also recognized that the current system for educating agency staff was ineffective, noting that more agency staff were present than had signed the education sheet and that some agency staff were unaware of the care cards.
Failure to Follow Transfer Protocols Results in Resident Falls
Penalty
Summary
Staff failed to use the appropriate method of transferring a resident, resulting in two separate falls. The facility's policies required that at least two nursing assistants assist with mechanical lifts, and that specific devices such as the Sara Steady be used according to the care plan. Despite these clear directives, staff transferred a resident using only one staff member on two occasions, and used an improper lift during one of those occasions. On one occasion, the resident was transferred with an EZ stand instead of the required Sara Steady, and on another, the transfer was attempted by a single staff member, leading to the resident's knees coming out of the knee holders and the resident sliding to the floor. The resident involved had a complex medical history, including muscle wasting, severe obesity, vascular dementia, and arthritis, and was dependent on staff for transfers. The care plan and care card for the resident specified that transfers should always be performed with two staff members using a Sara Steady, with additional instructions to ensure the resident's knees remained together and stable during the transfer. Occupational therapy assessments and progress notes also confirmed the need for two-person assistance and the use of the Sara Steady for safe transfers. Despite these documented requirements, staff did not consistently follow the care plan or facility policy. Incident and event reports, as well as interviews with staff and therapy personnel, confirmed that on both occasions, the resident was transferred incorrectly, either with the wrong equipment or with insufficient staff assistance. These failures directly resulted in the resident experiencing falls during transfers, although no injuries were reported.
Failure to Assess and Notify Physician Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure a comprehensive assessment was performed for a resident, identified as R291, who experienced a significant change in condition. R291, who had a history of Transient Ischemic Attack, Vascular Dementia, Chronic Kidney Disease stage 3, Chronic Obstructive Pulmonary Disease, and Diabetes type 2, began having increased difficulty with transfers and eating. Despite these changes, the Registered Nurse (RN) on duty did not take a full set of vital signs or perform a comprehensive assessment, nor was the physician notified of the change in condition. On a subsequent day, R291 became unresponsive and was transferred to the hospital with a diagnosis of severe sepsis, where the resident later expired. The facility's policy required that any change in condition should prompt a notification to the attending physician, especially during non-office hours, and a full set of vital signs should be taken. However, this protocol was not followed, as evidenced by the lack of documented vital signs and the absence of physician notification. Interviews with staff and the resident's healthcare power of attorney revealed that the RN did not perceive the severity of R291's condition, leading to a delay in appropriate medical intervention. The failure to conduct a thorough assessment and notify the physician resulted in a finding of immediate jeopardy, indicating a reasonable likelihood for serious harm to the resident.
Removal Plan
- The Change of Condition policy has been reviewed by DON and modified with the following modifications: Examples of Change of Condition, Use of Interact tools - include the change of condition pathways and Stop and Watch, VS will be taken immediately or as soon as possible with any change of condition. Once VS and immediate assessment is completed, MD will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order.
- All changes in condition will be listed on the 24-hour report board.
- Nurse practitioner will provide education to all nurses related to recognition of physiological changes of condition as well as behavioral responses that may indicate a physiological change in condition. Education will include response including interventions, notifications, and documentation. This education will be taped and all nurses not present will be required to view the in-service prior to their next working shift.
- Nurse involved in incident was part of the NP's education and was also provided one on one education by the DON and ADON on physiological change of condition and behavioral responses that may indicate a change of condition and expectations for response and notification.
- Interact tools have been implemented and are available electronically within the electronic medical record as well as all Interact tool change of condition pathways have been printed and are located at each nursing station. All licensed staff have been educated on the use of Interact tools as well as their location.
- All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse.
- Post tests will be given following the education to ensure competency.
- Medical Director consulted during the development of this corrective action plan.
- The DON and ADON will review progress notes and 24-hour report board daily for any changes of condition to ensure audits will continue with ad hoc training provided as necessary for any missed opportunities. Audits will continue. All audits and results will be brought to the quality improvement committee for review.
Inadequate Supervision and Assistance Devices for Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident identified as a wander/elopement risk due to altered mental status and dementia. The resident, who was severely cognitively impaired, had a history of wandering behavior and required partial/moderate assistance with mobility. Despite being identified as a risk, the facility placed the resident's Wanderguard bracelet on the wheelchair, even though the resident was capable of standing and ambulating independently. This led to two separate elopement incidents where the resident was found outside the facility, once in the rain and once at 1 am. The facility's policy required that residents at risk for elopement have a Wanderguard placed on their person and be monitored for proper functioning and placement daily. However, the resident's Wanderguard was placed on the wheelchair, which did not prevent the resident from leaving the facility. The facility's staff were aware of the resident's elopement risk and had documented multiple instances of the resident attempting to leave the facility, yet the Wanderguard was not consistently placed on the resident's person. Additionally, there was no investigation conducted for the first elopement incident, and the facility's policy did not consider an elopement to have occurred unless the resident left the facility grounds. The facility's inaction and failure to adhere to its own policies and procedures regarding elopement prevention contributed to the resident's ability to elope on two occasions. The lack of adequate supervision and proper placement of the Wanderguard created a reasonable likelihood for serious harm to the resident. The facility's deficient practice was identified as immediate jeopardy, indicating a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.
Failure to Investigate Infectious Outbreaks
Penalty
Summary
The facility failed to thoroughly investigate four infectious disease outbreaks, including two COVID-19 outbreaks, a norovirus outbreak, and an influenza outbreak, occurring between August 2023 and January 2024. The documentation provided for each outbreak was limited to line lists for residents and staff, and records of PPE and handwashing training. There was no documentation of investigations into the source of the outbreaks or any findings related to the cause of the outbreaks. The Infection Preventionist (IP-C) was unaware of the requirement to complete and document investigations into the outbreaks. During an interview, the IP-C mentioned having email communications with the county public health department regarding the outbreaks, but these were not initially provided to the surveyor. After the survey team exited the facility, the facility submitted copies of these emails, which included line lists and documentation of interventions such as cleaning and isolation. However, no additional documentation was provided to explain the source of the outbreaks or why they were not thoroughly investigated.
Failure to Provide Transfer Notices
Penalty
Summary
The facility failed to provide timely transfer or discharge notices to residents, as required by regulations. Specifically, four residents (R2, R17, R30, and R34) did not receive written notices that included the date of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This deficiency was identified during a survey when the Nursing Home Administrator (NHA) admitted that no transfer notices were issued to these residents. The facility's policy, which mandates that notice of transfer be provided to the resident and representative as soon as practicable before the transfer, was not followed. The report details specific instances where residents were transferred to hospitals without receiving the required notices. For example, R34 was sent to the hospital on 8/2/24 due to a change in condition but did not receive a transfer notice. Similarly, R17 was discharged with an anticipated return on two occasions, yet no transfer consent documentation was available. The NHA acknowledged that no one in the facility was responsible for issuing transfer notices, which was identified as the main problem. This lack of documentation and adherence to policy was confirmed through interviews and record reviews conducted by the surveyor.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R13, to the state survey agency as required by their policy. R13, who has a cognitive status indicating intact mental faculties, was found with bruising on her inner left thigh and knee. Despite the resident's inability to recall how the bruises occurred, the facility did not report the incident within the mandated 24-hour period. The facility's policy requires immediate reporting of such incidents, but this was not adhered to in this case. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were not aware of the bruising until prompted by the surveyor, indicating a breakdown in communication and procedure. The DON was on vacation, and the nurse responsible for reporting skin issues did not inform the DON or NHA. The NHA admitted to starting the investigation late and had not reported the incident to the state survey agency. The facility also failed to submit the findings of their investigation within the required five working days, further compounding the deficiency.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as R13, who was observed with bruising on her inner left thigh and knee. R13, who is cognitively intact but dependent on staff for activities of daily living, could not explain how the injuries occurred. The facility's policy requires immediate investigation of such injuries to rule out abuse, especially when the injury is in an area not vulnerable to trauma. Despite this, the facility did not initiate an investigation when the bruising was first documented by staff during a bath, nor did they report the injury to the state survey agency. The Nursing Home Administrator (NHA) admitted to the surveyor that an investigation had only begun the day before the interview, as they were not made aware of the incident earlier. The Director of Nursing (DON) was on vacation and also unaware of the situation, indicating a breakdown in communication and protocol adherence. The facility's failure to investigate promptly and report the injury as required by their policy resulted in a deficiency noted by the surveyors.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified during a survey when it was found that three residents, identified as R2, R30, and R34, did not receive the necessary documentation regarding the duration of the bed hold policy, the reserve bed payment policy, and their right to return to the facility. Specifically, R34 was transferred to the hospital on 8/2/24 due to a UTI and C-Diff infection, but no bed hold notice was provided. Similarly, R2 and R30 were transferred to the hospital on 6/25/24 and 2/12/24, respectively, without receiving the required written information. The facility's policy, dated 10/22, mandates that residents or their representatives be given written information about bed hold policies at the time of transfer or within 24 hours in emergency situations. However, during interviews, the Nursing Home Administrator (NHA) admitted that no written bed hold information was provided to the residents in question and acknowledged that there was no designated person responsible for issuing these notices. This lack of accountability and adherence to policy resulted in the failure to inform residents of their rights and the facility's bed hold procedures during hospital transfers.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was admitted with an indwelling catheter. The resident, who had a diagnosis of neurogenic bladder and a history of failed voiding trials, was admitted to the facility with the catheter in place. Despite the resident's condition and the presence of the catheter since admission, the facility did not create a care plan addressing the services required for the resident's long-term catheter use. This omission was noted during a surveyor's review of the resident's electronic medical record, which lacked any documentation of a care plan for the catheter. The deficiency was further highlighted by the resident's occasional refusals to participate in voiding trials and care procedures, which were not addressed in a care plan. The surveyor observed the resident with the catheter in place and noted that the facility's staff had not developed a plan of care based on a comprehensive assessment. The Nursing Home Administrator confirmed that a care plan should have been completed upon admission and updated with any changes, but it was not done, leading to the deficiency noted in the report.
Improper Labeling and Dating of Resident's Medications
Penalty
Summary
The facility failed to ensure that medications used by a resident during a medication pass were properly labeled and dated with an expiration date. During an observation, a surveyor noted that a resident received a multivitamin with minerals, Vitamin D, and Zinc from bottles that were not labeled with the resident's name, did not have an expiration date, and were not marked with an open date. The Licensed Practical Nurse (LPN) administering the medications confirmed that the vitamins were purchased by the resident and lacked proper labeling and expiration information. The facility's policy requires that any medications brought in by residents or their families must be reported to the nursing staff and have an open date. However, the vitamins in question did not comply with this policy. The Director of Nursing (DON) was informed of the observations and acknowledged the lack of labeling and expiration dates on the bottles but could not provide additional information on why the medications were administered without proper labeling and dating.
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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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