Eastview Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Antigo, Wisconsin.
- Location
- 729 Park St, Antigo, Wisconsin 54409
- CMS Provider Number
- 525410
- Inspections on file
- 18
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Eastview Health And Rehabilitation Center during CMS and state inspections, most recent first.
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 with severe cognitive impairment and a history of falls developed bruising on the legs and buttocks from multiple falls and behaviors. Despite facility policy requiring notification, the POAHC was not informed of these injuries, and documentation confirmed the lack of notification. The DON acknowledged the failure to notify, and the POAHC only became aware of the bruising when the resident was sent to the ER.
A resident with severe cognitive impairment and a history of falls was admitted for rehabilitation after a traumatic brain injury. Despite being assessed as high risk for falls, no individualized fall interventions were included in the care plan upon admission, and the resident experienced multiple unwitnessed falls before any interventions were implemented. The DON confirmed that required fall interventions were not added to the care plan as per facility policy.
A resident with multiple medical conditions was admitted with hospital discharge instructions to hold clopidogrel (Plavix) prior to a scheduled stent removal. The facility failed to stop the medication and missed the stent removal appointment because key staff did not fully review all admission paperwork, resulting in continued administration of the medication against orders.
The facility failed to ensure food safety and sanitation, affecting all 52 residents. Staff did not monitor or document cooked food temperatures, test sanitizing solutions, or discard expired food items. Observations revealed improper hand hygiene during meal service and cold food items not maintained at safe temperatures. The Dietary Manager acknowledged these issues and was in the process of creating procedures to address them.
A long-term care facility failed to ensure safe medication administration for four residents, leaving medications at the bedside without proper assessments or physician orders for self-administration. Residents with varying levels of cognitive impairment were found with medications like miconazole nitrate and polyethylene glycol left unattended, and treatments were documented as administered without being completed. The Director of Nursing confirmed the lack of proper assessments and orders, indicating a systemic issue in the facility's medication administration practices.
A facility failed to maintain an effective infection prevention and control program. A resident with an open wound was not placed under Enhanced Barrier Precautions, and another resident with multiple infections was not included on the infection control line list. Additionally, an LPN did not perform hand hygiene between administering medications to different residents, highlighting lapses in infection control practices.
A resident with moderate cognitive impairment was transferred to the hospital for a left hip fracture without receiving a written transfer notice. The facility did not provide the notice to the resident or their emergency contact, and the Nursing Home Administrator confirmed that transfer notices are not issued, only bed hold notices. The facility also lacked a policy on transfer/discharge notices.
A resident with intact cognition and multiple medical conditions did not receive required bed hold notices for frequent therapeutic leaves, as the facility's DON was unaware of the requirement. The facility's census inaccurately documented these absences, leading to a deficiency in compliance with the Therapeutic Leave policy.
A resident admitted with a pressure ulcer did not receive appropriate care due to inaccurate wound assessments and documentation. The facility failed to include the pressure injury in the resident's MDS assessment and diagnoses list, and the resident was not placed on enhanced barrier precautions. The Director of Nursing and Registered Nurse Manager confirmed the assessments were incorrect, and the resident's request for a pressure-relieving cushion was initially unmet.
A resident with an indwelling catheter experienced a deficiency in care when their catheter was flushed without a physician's order, and the care plan lacked an intervention for flushing if obstructed. The resident's urine was often discolored, but documentation was insufficient, and the facility lacked standing orders for catheter flushing. The Director of Nursing confirmed the need for proper orders and documentation.
A resident experienced significant unplanned weight loss, but the facility failed to ensure proper weight monitoring as per policy. The resident's medical record lacked a current order for weight monitoring, and staff did not record weights after a certain date. Interviews with the RD and DON confirmed the oversight, acknowledging that more frequent weight checks should have been ordered following the resident's weight loss.
A resident with dementia and COPD was observed self-administering a nebulizer treatment incorrectly, with inadequate supervision and assessment by facility staff. The resident was left unsupervised during treatment, leading to improper use, and the facility's policies for medication administration were not followed. Despite an evaluation indicating the resident's inability to manage medications, they were still allowed to self-administer the nebulizer treatment.
A resident with end-stage renal disease did not have their pre and post-dialysis communication forms retained in their medical record. The facility's DON discarded these forms after a short period, and the information was only recorded if action was needed. This resulted in an incomplete medical record, contrary to the facility's policies.
A resident was admitted to the facility on an antibiotic without a specified stop date, contrary to the facility's Antibiotic Stewardship Protocol. The resident's MAR lacked a stop date for azithromycin, and staff interviews revealed a lack of awareness and communication regarding the antibiotic's duration. This indicates a failure to adhere to the established protocol for managing antibiotic use.
The facility failed to offer pneumococcal vaccines to two residents as per CDC guidelines. The residents' medical records lacked documentation of vaccine declination or discussions of risks and benefits. The Infection Preventionist identified residents due for the PCV20 vaccine, but the Medical Director instructed not to administer them, resulting in the residents not being offered the vaccines.
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 Notify POAHC of Resident Injuries After Multiple Falls
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's Power of Attorney for Healthcare (POAHC) of injuries resulting from multiple falls. The resident, who was severely cognitively impaired with a BIMS score of 0 and had diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and a history of falls, developed bruising on the legs and buttocks. Progress notes documented the presence of bruising and falls, but there was no indication that the POAHC was informed about the injuries, despite facility policy requiring notification of such changes in condition. Interviews and record reviews confirmed that the POAHC was not made aware of the bruising until the resident was sent to the emergency room, where the injuries were observed. The DON acknowledged that there was no documentation of notification to the POAHC regarding the bruising. The POAHC expressed distress at not being informed of the injuries, and the facility's own investigation and skin assessments confirmed the bruising was consistent with multiple falls and behaviors, yet notification was not provided as required.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with a known history of falls and significant cognitive impairment. Upon admission, the resident was assessed as high risk for falls due to diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and a previous traumatic subdural hemorrhage. Despite this, the baseline care plan did not include any fall interventions, and the comprehensive care plan was not updated with fall interventions until several days after admission. The resident experienced multiple unwitnessed falls within the facility shortly after admission, yet no individualized fall interventions or safety measures were implemented following these incidents. Interviews with the resident's Power of Attorney for Healthcare (POAHC) and the Director of Nursing (DON) confirmed that fall interventions were not added to the care plan upon admission or after the initial falls. The DON acknowledged that 15-minute checks were conducted as a standard practice for new admissions but were not individualized fall interventions. The facility's own Fall Reduction Policy required individualized interventions and care plan updates after each fall, which were not followed in this case.
Missed Medication Hold and Appointment Due to Incomplete Review of Admission Orders
Penalty
Summary
A resident with diagnoses including acute kidney injury, bladder cancer, complicated UTI, and atrial fibrillation was admitted to the facility following a hospital stay. The resident's hospital Discharge Summary included an order to stop clopidogrel (Plavix) on a specific date pending a scheduled urinary stent removal. The After Visit Summary (AVS) also indicated a follow-up appointment for stent removal and other specialist visits. Despite these instructions, the facility continued to administer clopidogrel to the resident from admission through discharge, as documented in the Medication Administration Record (MAR), and did not stop the medication as ordered. The deficiency occurred because the facility failed to accurately review and implement the hospital discharge instructions and AVS. The stent removal appointment and the order to hold clopidogrel were missed during the admission process. Key staff, including the Admissions Director and Director of Nursing, did not see the relevant orders, as some paperwork was only scanned into the medical record without being reviewed in paper form. The oversight was only discovered after the resident's family brought the missed appointment to staff attention.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, potentially affecting all 52 residents. Staff did not monitor or document cooked food temperatures, as required by the 2022 FDA Food Code and the facility's own policies. During an initial tour of the kitchen, the Dietary Manager (DM) confirmed that kitchen staff only completed one set of temperatures prior to meal service and did not consistently monitor or document cooking temperatures. The DM acknowledged awareness of this requirement only recently and had not yet implemented a procedure to address it. Additionally, the facility did not test or document the parts per million (PPM) of the quaternary sanitizing solution as per the manufacturer's instructions. The DM admitted that kitchen staff did not use test strips to test the sanitizing solution in the sanitizing buckets. This oversight was also recently recognized by the DM, who was in the process of creating a procedure to rectify the issue. The facility also failed to discard food items beyond their expiration or use-by dates and did not store them in a manner to prevent cross-contamination. During the kitchen tour, the surveyor noted several expired items, including sour cream and heavy cream, which the DM intended to discard but had forgotten. Furthermore, staff did not complete appropriate hand hygiene during meal service, as observed when a cook and a dietary aide handled food and utensils with contaminated gloves. Cold food items were not maintained at a proper temperature during meal service, with butterscotch pudding observed at temperatures above the safe limit, which was acknowledged by the DM.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure safe and accurate administration of medication for four residents, resulting in medication being left at the bedside without proper assessments or physician orders for self-administration. Resident 15, who had intact cognition, was found with miconazole nitrate 2% powder at the bedside and reported not receiving prescribed treatments for a rash under the breasts. The medical record indicated treatments were documented as administered, but the resident confirmed they were not completed, and the Licensed Practical Nurse (LPN) admitted to signing off on the treatment without administering it. Resident 6, with moderately impaired cognition, was observed with polyethylene glycol left on their wheelchair tray after medication administration. The resident did not have an order or assessment for self-administration, and it was unclear if the medication was consumed. Similarly, Resident 12, also with moderately impaired cognition, had polyethylene glycol left at the bedside with a portion remaining in the cup, despite not having an order or assessment for self-administration. Resident 7, with severely impaired cognition, was left with polyethylene glycol at the bedside after medication administration, with a quarter of the medication still in the cup. Like the other residents, there was no order or assessment for self-administration. The Director of Nursing confirmed that medications should not have been left with these residents without proper assessments and orders, highlighting a systemic issue in medication administration practices at the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One resident, identified as R207, had an open wound on the buttocks but was not placed under Enhanced Barrier Precautions (EBP) as required by the facility's policy. Despite having daily wound care orders, there was no order for EBP, and staff did not wear gowns during care. Interviews with the nursing staff, including the Director of Nursing and the Nursing Home Administrator, confirmed that R207 should have been on EBP due to the open wound. Another resident, R42, was not included on the facility's infection control line list despite having multiple diagnoses, including necrotizing fasciitis and several stage 4 pressure ulcers, and being on IV antibiotics. The Infection Preventionist confirmed that R42 was missed on the line list, although the resident was on contact precautions and had a sign indicating such on the door. The oversight in documentation and tracking of R42's infection status highlights a lapse in the facility's infection surveillance practices. Additionally, a Licensed Practical Nurse (LPN) failed to perform hand hygiene between administering medications to different residents, specifically R12 and R7. This breach of protocol was observed by the surveyor and later confirmed by the Director of Nursing, who acknowledged that hand hygiene should be completed between residents. These findings collectively indicate significant gaps in the facility's adherence to infection control policies and procedures.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident, identified as R52, who was transferred to the hospital. R52 was hospitalized for a left hip fracture, and neither the resident nor the emergency contact received a written transfer notice. The resident had a history of moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, but was still making their own healthcare decisions. During the survey, the Nursing Home Administrator acknowledged that the facility provides bed hold notices but does not issue transfer notices. Additionally, the facility did not have a policy related to transfer/discharge notices available for review.
Failure to Provide Bed Hold Notice for Therapeutic Leave
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as R42, who frequently left the facility for therapeutic leave. According to the facility's Therapeutic Leave policy, residents or their representatives should receive written information about a bed hold prior to or upon notice of transfer. However, R42, who left the facility for therapeutic leave approximately every other week from October 2024 to January 2025, did not receive any bed hold notices. This oversight was identified during a surveyor's review of R42's medical records and interviews with facility staff. R42 was admitted to the facility with diagnoses including septicemia, paraplegia, anxiety, depression, and post-traumatic stress disorder, and had an intact cognitive status as indicated by a BIMS score of 15 out of 15. Despite having multiple therapeutic leaves, the Director of Nursing (DON) acknowledged that no written bed hold notices were provided to R42, as the DON was unaware that such notices were required for therapeutic leaves. The facility's census inaccurately documented R42's absences as hospitalizations, further complicating the situation.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for a pressure injury for one resident, identified as R207, among 24 sampled residents. R207 was admitted with a pressure ulcer on the buttock, but the facility did not complete accurate weekly wound assessments or include the pressure injury diagnosis on the resident's Minimum Data Set (MDS) assessment and diagnoses list. The facility's Wound Care Policy required weekly documentation of skin impairments, but initial and weekly assessments inaccurately indicated no skin alterations. R207's medical record review revealed inconsistencies, as the hospital discharge paperwork noted an active pressure ulcer with a treatment order for Silver Sulfadiazine cream. However, the initial admission skin assessment and subsequent weekly assessment failed to document the wound. Interviews with the Director of Nursing (DON) and Registered Nurse Manager (RNM) confirmed the assessments were incorrect, and the wound assessments were not properly documented in the medical record. Additionally, R207 was not placed on enhanced barrier precautions (EBP) for the open wound, and the resident's request for a pressure-relieving cushion was initially unmet. The DON acknowledged being behind in charting and confirmed that the wound assessments were not entered correctly. The MDS Coordinator relied on the facility's inaccurate assessments, leading to the omission of the pressure injury from the MDS assessment and diagnoses list. The Nursing Home Administrator admitted that the wound care information was missed, and the assessments should have been accurate to ensure proper care and follow-up. The failure to document and assess the wound accurately hindered the facility's ability to monitor the wound's condition and provide appropriate care.
Deficiency in Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter, leading to a deficiency. The resident, who had intact cognition and was their own decision-maker, was admitted with a Foley catheter in place since 2018 due to conditions such as benign prostatic hypertrophy, urinary retention, and neurogenic bladder. The care plan for the resident included monitoring and reporting signs of urinary tract infection and changes in urine color but did not include an intervention for flushing the catheter if obstructed with clots. On one occasion, the resident's catheter was flushed without a physician's order after the resident exhibited dark cherry-colored urine, which was not documented in the medical record. The resident's urine was often light pink or cherry-colored, attributed to the resident pulling on the catheter. Despite the presence of clots and poor drainage, there was no documentation of the catheter being flushed or the urine's discoloration until a phone order was received later to allow flushing as needed. The Director of Nursing confirmed that there should have been an order to flush the catheter before the intervention and that the care plan lacked an intervention for flushing the catheter if obstructed. Additionally, the facility did not have standing orders for flushing catheters, and there was a lack of documentation regarding the urine color, which should have been reported and documented according to the Director of Nursing.
Failure to Monitor Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R43, received the necessary care and services to monitor significant weight loss. R43 experienced an unplanned weight loss of 15.72% between September 13, 2024, and January 1, 2025, with a 5.26% weight loss between December 9, 2024, and January 1, 2025. Despite this significant weight loss, R43's medical record did not contain a current order for weight monitoring, and staff did not monitor R43's weight according to the facility's policy. The facility's Weight Monitoring policy requires a weight monitoring schedule to be developed upon admission, with weekly monitoring for residents experiencing weight loss. However, R43's order for weekly weights was discontinued on December 9, 2024, and no additional weights were recorded after January 1, 2025. Interviews with the Registered Dietitian (RD) and the Director of Nursing (DON) confirmed the lack of a current order for weight monitoring and acknowledged that more frequent weights should have been ordered following R43's significant weight loss. The RD confirmed that R43 should have had a more recent weight than January 1, 2025, and typically, weekly weights for four weeks are ordered in such cases. The DON was aware of R43's weight loss but was unable to provide further information to confirm that R43's weight had stabilized since January 1, 2025. R43, who had intact cognition, was aware of the weight loss and expressed a goal to regain weight but was uncertain of the current weight and did not recall the last time they were weighed.
Inadequate Supervision and Assessment for Nebulizer Treatment
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory care and services for a nebulizer treatment. The resident, who had been admitted with diagnoses including dementia, COPD, and hypertension, was observed self-administering a nebulizer treatment incorrectly on two occasions. On the first occasion, the resident was found asleep with the nebulizer mouthpiece hanging out of their mouth, not fully inhaling the treatment. On the second occasion, the resident was left unsupervised during the treatment, repeatedly removed the nebulizer to talk, and eventually placed it on the table while it was still running. The resident's self-administration of medication evaluation indicated they could not correctly identify medication names, side effects, or dosages, yet they were deemed able to self-administer the nebulizer treatment. The facility's policies and procedures for administering medications and nebulizer use were not followed. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) indicated that the resident was assessed as able to self-administer the nebulizer treatment, but the evaluation was completed after the surveyor's initial observation. The DON acknowledged that the facility's policy was incorrect regarding the need for a respiratory assessment before or after nebulizer treatments. The resident's self-administration evaluation was re-evaluated, revealing further deficiencies in the resident's ability to manage their medications, yet a physician's order for self-administration of nebulizer treatments was obtained upon admission.
Incomplete Medical Record for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurate and complete, specifically for a resident with end-stage renal disease who received dialysis services. The resident, who had intact cognition and made their own medical decisions, did not have their pre and post-dialysis communication forms retained in their medical record. The facility's Medical Record Release Policies and Procedures require documentation to accurately describe the resident's condition and any changes in treatment, but this was not adhered to in the case of the resident. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) described the process for documenting and communicating dialysis information, which involved faxing a Dialysis Pre and Post Communication form to the dialysis center and providing a copy to the DON. However, the DON admitted to discarding these forms after a short period, and the information from the forms was only entered into the resident's medical record if the DON had to take action. This practice resulted in the absence of critical documentation in the resident's medical record, leading to the deficiency identified by the surveyor.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to consistently follow its antibiotic stewardship program, as evidenced by the case of a resident who was admitted on an antibiotic without a specified stop date. The resident, who had intact cognition and was diagnosed with type 2 diabetes mellitus with neuropathy, congestive heart failure, and chronic respiratory failure with hypoxia, was prescribed azithromycin 250 mg to be taken three times weekly. However, the medication administration record (MAR) did not include a stop date or duration for the antibiotic, which is a requirement under the facility's Antibiotic Stewardship Protocol. Interviews with facility staff revealed a lack of awareness and communication regarding the antibiotic's duration. The Nursing Home Administrator was unaware of the stop date, and the Director of Nursing confirmed that the nursing staff should have sought clarification from the resident's physician upon admission. The Infection Preventionist also verified the absence of a stop date and acknowledged that antibiotics should have specified durations. This oversight indicates a failure to adhere to the established protocol for reviewing and managing antibiotic use within the facility.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered to two residents, R24 and R34, as per CDC guidelines. The medical records for these residents did not contain declination forms for the pneumococcal vaccines, nor did they indicate that the risks and benefits of the vaccines were discussed with the residents or their representatives. Specifically, R34 should have been offered the PCV20 vaccine in 2020, five years after receiving the PCV13 vaccine in 2015, and R24 should have been offered the PCV20 vaccine in 2022, five years after receiving the PPSV23 vaccine in 2017. The Infection Preventionist (IP)-K had compiled a list of residents due or past due for the PCV20 vaccine and presented it to the Medical Director (MD)-T. However, MD-T instructed not to administer the vaccines, and as a result, the residents were not given the option to receive the vaccine. This decision led to the failure in offering the vaccines to the residents, as confirmed by interviews with the Director of Nursing (DON)-B and IP-K. The facility's policy required that residents be offered the recommended vaccines upon admission, with documentation of education and the opportunity to refuse, which was not adhered to in this case.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
