Eden Rehab Suites And Green House Homes
Inspection history, citations, penalties and survey trends for this long-term care facility in Oshkosh, Wisconsin.
- Location
- 3151 Eden Ct, Oshkosh, Wisconsin 54904
- CMS Provider Number
- 525704
- Inspections on file
- 15
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Eden Rehab Suites And Green House Homes during CMS and state inspections, most recent first.
A resident with intact cognition and a history of acute and chronic respiratory failure with hypoxia and COPD requested a copy of their medical record in writing, with a family member also involved in the request. The NHA received the email requests and indicated the facility had up to 30 days to respond, while the SW was unsure of the required timeframe. The DON reported there was no specific policy for handling medical record requests. Although the NHA had a paper copy of the record and was planning an internal review meeting before release, the resident had not received the requested records within the required timeframe, resulting in a deficiency for failure to provide timely access to medical records.
A hospice patient with metastatic cancer, chronic pain, and a stage 4 pressure ulcer repeatedly reported pain at 9–10/10, became verbally aggressive, and requested IV pain medication that the facility could not provide. Staff believed the resident had received the maximum scheduled and PRN pain medications and, after the resident agreed to go to the hospital, an RN notified the DON and arranged transfer to the ER without first notifying hospice, and did not initially notify the POAHC. The hospice agency later reported it had not been informed of the resident’s escalating pain or behavior before the day the resident was sent to the ER, and stated the resident’s pain regimen could have been adjusted.
Two residents were transferred to the hospital and did not receive proper written bed-hold and transfer/discharge notices with required appeal rights information. One resident with metastatic cancer, chronic pain, a stage 4 pressure ulcer, and moderate cognitive impairment, represented by an activated POA, was told by the admissions staff that the resident was being kicked out and would not be allowed to return, and neither the resident nor the POA received any written bed-hold or transfer/discharge notice. Another resident with acute on chronic combined systolic and diastolic CHF and aspiration pneumonia, who was cognitively intact and made their own healthcare decisions, signed a bed-hold/transfer form that lacked mandated appeal rights details, including contact information for the appeals entity and instructions on obtaining and submitting an appeal. The DON acknowledged that the facility used the bed-hold form as its policy, had no separate policy, and was unaware of the requirement to include appeal rights on these notices.
Staff failed to follow facility policy and MD orders for respiratory care when a resident with COPD, acute and chronic respiratory failure with hypoxia, acute pulmonary edema, and heart failure received nebulizer treatments. Although the MAR showed that nebulizer treatments were given and the resident self-administered them after nurse set-up, nursing staff did not consistently assess or document required pre- and post-treatment parameters such as lung sounds, pulse, respirations, and oxygen saturation as directed. The DON confirmed that nebulizer assessments should be documented on the MAR and that this was not consistently done for this resident.
A hospice resident with metastatic cancer, chronic pain, and opioid dependence experienced uncontrolled pain rated 10/10 despite having both scheduled and PRN morphine and adjunctive medications ordered. CNAs and the DON reported the resident repeatedly requested pain medication, exhibited distress and behavioral changes, and refused some non-pharmacologic interventions and assessments. The RN administered scheduled and one PRN morphine dose, documented it as effective despite ongoing aggressive behavior, and reported offering additional PRN morphine later, but the medical record showed no documentation of further offers or refusals and confirmed that more PRN morphine could have been given before the resident was transferred. Facility staff told hospice and the hospital that the resident had “maxed out” on pain medications and was being sent to the ER for uncontrolled pain and behavior, while hospice reported the resident had not reached maximum dosing and that the facility declined hospice’s offer to assess and adjust the pain regimen before transfer.
Surveyors found that the facility failed to maintain sanitary conditions in the kitchen, including a microwave with dried food debris, improperly stored and outdated food items in the refrigerator, and a dishwasher that did not reach the required sanitizing temperature. These deficiencies were observed during a kitchen inspection and had the potential to affect all residents.
Two residents with activated POAHC due to incapacity had healthcare decisions made or consents signed by individuals not authorized as their healthcare agents. In one case, a family member not listed in the POAHC made decisions, and in another, the incapacitated resident signed their own medical consents instead of the designated agent. Staff confirmed these actions were not in accordance with facility policy or state law.
A resident with Alzheimer's disease, moderate cognitive impairment, and mobility needs was repeatedly observed with their call light out of reach while in bed. The resident was unable to access the call light when needing assistance, and staff confirmed the device was not accessible as required by facility policy.
The facility did not ensure timely and accurate completion of PASRR Level I and Level II screenings or obtain required county exemption forms for three residents with mental illness diagnoses and/or prescribed psychotropic medications. PASRR documentation was not updated to reflect medication changes, and necessary screenings were not submitted when residents remained in the facility beyond 30 days.
Two residents did not receive timely and appropriate assistance with ADLs. One resident with a large perirectal wound was left in urine or stool for extended periods due to delayed call light response and inadequate incontinence care, while another resident discharged from PT did not receive the recommended restorative ambulation program, with staff unaware of the walking schedule and the care plan lacking this intervention. Facility policies requiring timely response and maintenance of ADL abilities were not followed.
Multiple residents with cognitive impairment and a history of falls experienced repeated unwitnessed falls without thorough investigation, root cause analysis, or updates to their care plans. Required neurological checks were often incomplete or missing, and the facility did not consistently follow its own fall procedures. The DON confirmed that fall investigations, care plan updates, and neuro checks were not properly completed after these incidents.
Surveyors observed that two residents with indwelling medical devices did not receive care in accordance with infection control and Enhanced Barrier Precautions (EBP) policies. During perineal care, staff failed to perform hand hygiene between glove changes, did not wear required gowns, and did not ensure EBP signage or PPE carts were present. Staff and nursing leadership confirmed these actions did not meet facility policy requirements.
The facility failed to complete ordered wound care for two residents, leading to immediate jeopardy for one. A resident with Charcot's foot did not receive daily dressing changes, resulting in maggots in the wound and hospital transfer. Another resident's dressing change was missed, with no documentation of completion. The deficiencies were due to lapses in following prescribed wound care regimens.
The facility did not ensure food was stored and prepared in a sanitary manner, with items in the kitchen cooler not listed on the cooling log and kitchenettes found in unsanitary conditions. The Dietary Manager confirmed that the facility's process for documenting food cooling temperatures and daily cleaning of kitchenettes was not being followed.
A resident with severe cognitive impairment and multiple diagnoses experienced several falls resulting in injuries due to the facility's failure to implement fall prevention interventions as outlined in the care plan. Observations revealed the bed was not in the lowest position and the floor mat was not in place, despite these measures being required.
Failure to Provide Timely Access to Requested Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to a resident’s medical record after a written request. A resident with intact cognition, as evidenced by a BIMS score of 15/15 on an MDS assessment dated 12/10/25, had been admitted with diagnoses including acute and chronic respiratory failure with hypoxia and COPD with acute exacerbation, and was discharged on 12/10/25. The resident and a family member submitted a written request for the resident’s medical record to the Nursing Home Administrator via email on 1/20/26, followed by a signed formal request sent via email on 1/22/26. As of 2/5/26, the resident had not received the requested records. The family member reported that the NHA responded by email stating the facility had up to 30 days to provide the records. During interviews, the DON stated the facility did not have a policy for medical record requests and instead followed state and federal regulations. The Social Worker acknowledged awareness of the resident’s request but was uncertain of the required timeframe for releasing records, estimating it to be 48 hours. The NHA showed the surveyor a paper copy of the resident’s medical record and stated that a meeting to review the records, originally planned for 2/4/26, had been postponed to 2/6/26, and that the NHA intended to call the resident after the meeting to inform them the records were ready for pickup. Despite the request and internal awareness of it, the records had not been provided to the resident within the required timeframe, resulting in the deficiency related to timely access to medical records.
Failure to Notify Hospice of Uncontrolled Pain Prior to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a hospice agency in a timely manner about a resident’s uncontrolled pain and escalating behavior. The resident was admitted on hospice services with multiple serious diagnoses, including metastatic prostate cancer to the bone, a stage 4 right heel pressure ulcer, osteomyelitis, cervical radiculopathy, chronic pain, peripheral neuropathy, and opioid dependence. The resident’s cognition was assessed as modified independent, and a Power of Attorney for Healthcare (POAHC) had been activated. Staff interviews and record review showed that the resident repeatedly reported pain at 9–10 out of 10, requested IV pain medication that the facility could not provide, and became verbally aggressive and impatient with call light response times. The Admissions Coordinator reported being informed that the resident had “maxed out” on pain medications and still had pain at 10 out of 10, and stated that hospice and family were notified that the resident’s pain remained uncontrolled and that the resident was requesting more pain medication than the facility could provide. However, the Hospice Director of Clinical Services stated hospice had not received any reports of uncontrolled pain or escalating verbally aggressive behavior prior to the morning when the Nursing Home Administrator and Admissions Coordinator informed hospice that the resident’s pain was 9–10 out of 10 and that the resident was being sent to the ER. The Hospice Director also stated the resident had not actually “maxed out” on pain medication and that medications could have been adjusted. The DON reported that the RN had given all pain medication the resident could have per facility understanding, found it ineffective, notified the on-call provider, and sent the resident to the ER, but could not recall if hospice was contacted before the transfer. The RN confirmed not notifying hospice prior to sending the resident to the hospital, stating the resident’s mind was made up about going to the hospital, and also verified not initially notifying the POAHC. The resident was sent to the ER and later died in the hospital.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices With Appeal Rights
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices, including appeal rights information, to residents who were transferred to the hospital. For one resident (R2), who had metastasized prostate cancer, a stage 4 pressure ulcer to the right heel, opioid dependence, spinal stenosis of the cervical region, chronic pain, and moderate cognitive impairment, the record showed a hospital transfer on 1/23/26 due to chronic pain and refusal of care. R2 had an activated POA assisting with healthcare decisions. Interviews with the POAs indicated that the Admissions Coordinator informed them that R2 was being kicked out and would not be allowed to return because of complaints of pain, behaviors, refusal of care, uncontrolled pain, and combative behavior. The medical record did not contain any written bed-hold or transfer/discharge notice for R2 or the POAs, and the Admissions Coordinator confirmed that no such notice or discussion occurred. The DON confirmed that no bed-hold or transfer/discharge notice was reviewed or provided because the facility would not accept R2 back and stated unawareness of the requirement to provide such notices, including information on return rights and appeal rights, for all residents transferred to the hospital. For another resident (R13), who had acute on chronic combined systolic and diastolic congestive heart failure, aspiration pneumonia, and intact cognition with responsibility for their own healthcare decisions, the record showed a hospital transfer on 2/1/26. R13’s signed “Bed-Hold for Hospitalization and Therapeutic Leave/Discharge” form was present but lacked required information on appeal rights. Specifically, the form did not include the name, mailing and email address, and telephone number of the entity that receives appeal requests, nor did it provide information on how to obtain an appeal form or receive assistance with completing and submitting an appeal hearing request. The DON stated they were not aware that bed-hold and transfer/discharge notices must include information on appeal rights and verified that the facility’s form did not contain the required appeal information. The DON also indicated that this same form functioned as the facility’s policy and that there was no separate bed-hold or transfer/discharge policy.
Failure to Perform and Document Required Respiratory Assessments for Nebulizer Treatments
Penalty
Summary
Staff failed to provide and document required respiratory assessments in connection with nebulizer treatments for one resident. The facility’s Respiratory policy dated 1/2025 requires qualified nursing staff to assess a resident’s pulse, oxygen saturation, and lung sounds prior to nebulizer administration, and to reassess pulse, oxygen saturation, minutes of nebulizer use, and lung sounds after administration, with all respiratory nursing documentation to include pre- and post-nebulizer treatment assessments. The resident involved had physician orders to self-administer nebulizers and an inhaler after nurse set-up three times daily, and a specific order to assess prior to administering nebulizer treatment and to document lung sounds, pulse, and respirations every six hours for COPD. The Medication Administration Record (MAR) showed that all nebulizer treatments were provided, but the ordered nebulizer assessments were not completed as required. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary edema, and heart failure, and had a BIMS score of 13/15, indicating intact cognition, with an activated POA for healthcare. Despite the resident’s respiratory conditions and the clear policy and physician orders, staff did not assess the resident’s lungs prior to set-up or after the self-administered nebulizer treatments, and these assessments were not consistently documented in the MAR. During interview, the DON confirmed that nebulizer assessments should be documented in the MAR and verified that the resident’s nebulizer assessments were not consistently documented, confirming the failure to follow the facility’s respiratory policy and the physician’s orders for respiratory assessment and documentation.
Failure to Collaborate With Hospice and Fully Utilize Ordered Analgesics for Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management to a hospice resident with metastatic prostate cancer, a stage 4 heel pressure ulcer, osteomyelitis, chronic pain, peripheral neuropathy, cervical radiculopathy, and opioid dependence. The resident had moderate cognitive impairment and an activated healthcare power of attorney. Facility policy required systematic recognition, assessment, treatment, and monitoring of pain, including use of appropriate pain assessment tools, observation of non-verbal indicators, collaboration with the prescriber and hospice, and reassessment and adjustment of medications when pain was not controlled. On the night shift prior to the event, the resident’s pain was documented as 0, but on the following morning shift the pain level was documented as 10 out of 10. On the morning in question, CNAs reported that the resident repeatedly requested pain or gas medication, was rude and demanding, and later was found balled up and non-verbal. Another CNA reported the resident stated they were waiting for pain medication, continued to report severe pain, refused breakfast, and declined non-pharmacological interventions such as an ice pack and repositioning. The DON stated the resident refused assessments on admission and again that morning, while reporting pain at 10 out of 10. The DON also stated that the assigned RN had provided all pain medication the resident could receive and that the pain remained at 10 out of 10, leading to a decision to send the resident to the ER for intractable, uncontrolled pain. However, review of the MAR with the DON showed that additional PRN morphine could have been administered before the transfer time, and the record did not show any documentation that PRN morphine was offered and refused after the 7:01 AM dose. The hospice Director of Clinical Services reported being told by facility staff that the resident had “maxed out” on scheduled and PRN pain medications and was being sent to the ER, but hospice determined the resident had not actually reached the maximum allowable pain medication. Hospice stated they could have assessed the resident and adjusted or increased pain medications, and offered to involve the hospice medical director and send a nurse, but the facility declined and proceeded with the ER transfer. The hospital case manager reported being informed that the resident was being sent back due to pain control and behavior concerns and that hospice had offered solutions which the facility declined. The RN caring for the resident stated the resident complained of pain everywhere at a level 10 out of 10, requested IV pain medication and higher doses of opioids than the facility could provide, and that scheduled and PRN morphine were given close together. The RN documented the PRN morphine as effective despite the resident’s continued aggressive behavior and reported offering additional PRN morphine later, but this offer and any refusal were not documented in the medical record. Hospice later reported that the resident’s hospitalization would not have been necessary had hospice been involved in managing the resident’s pain prior to transfer.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage and preparation practices during an inspection. The kitchen microwave was found to have dried food debris on the interior surfaces, indicating it was not cleaned in accordance with the facility's policy or the Wisconsin Food Code, which requires daily cleaning of microwave cavities and door seals. The Dietary Manager confirmed that the microwave should be cleaned after each use, but it was not cleaned until after the surveyor's observation. In the main kitchen refrigerator, surveyors observed a partially open container of marinara sauce that was past its use-by date and had not been discarded as required. Additionally, a package of celery was found open to air with an open date well beyond the recommended consumption period and without a use-by date. These findings demonstrate that the facility did not consistently follow proper food labeling, storage, and discard procedures as outlined in the Wisconsin Food Code and the facility's own policies. The facility's dishwasher was also found to be deficient. The machine failed to reach the minimum required rinse temperature of 180 degrees Fahrenheit, as indicated on the manufacturer's data plate and required by the Wisconsin Food Code. Despite multiple attempts to run the machine and intervention by the Maintenance Director, the rinse temperature remained below the required threshold, raising concerns about the effectiveness of dish sanitization. These deficiencies had the potential to affect all 35 residents residing in the facility.
Failure to Ensure Healthcare Decisions Made by Properly Delegated Representatives
Penalty
Summary
The facility failed to ensure that the right to make healthcare decisions was exercised only by individuals properly delegated by the resident, in accordance with applicable law, for two residents. In the first case, a resident with moderate dementia and an activated Power of Attorney for Healthcare (POAHC) had a designated agent who resigned. The facility allowed a family member, not listed as a healthcare agent in the POAHC document, to make healthcare decisions and sign medical consents for the resident. Staff interviews confirmed that the family member was not authorized to act as the healthcare agent, and the alternate agent listed in the POAHC was not contacted or involved. In the second case, another resident with moderate cognitive impairment and an activated POAHC was admitted with documentation confirming incapacity and the activation of their healthcare agent. Despite this, the facility had the resident, who was deemed incapacitated, sign multiple healthcare consent forms, including medication consents, a CPR directive, and a vaccine consent. Staff confirmed that the resident's POAHC should have been the one to sign these documents, not the resident themselves. Both incidents demonstrate that the facility did not follow its own policy or state law regarding the delegation of healthcare decision-making authority when a resident is deemed incapacitated. The facility failed to ensure that only the designated healthcare agent, as specified in the POAHC, was making or authorizing healthcare decisions for these residents.
Call Light Inaccessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when a resident's call light was not accessible while the resident was in bed, contrary to the facility's policy requiring call lights to be within reach. The resident, who had Alzheimer's disease, a history of urinary tract infections, moderate cognitive impairment (BIMS score of 9/15), and required assistance with transfers, ambulation, and toileting, was observed multiple times over the course of a morning with the call light lying on the floor approximately five feet from the bed. The resident used a wheelchair and walker and had an activated Power of Attorney for Healthcare. During interviews and observations, the resident indicated an inability to locate or reach the call light when needing to use the bathroom. Staff confirmed the call light was not accessible and acknowledged that it should always be within reach for all residents, as per facility policy. The Director of Nursing also confirmed that the call light should have been accessible at all times.
Failure to Ensure Timely and Accurate PASRR Screening and Documentation
Penalty
Summary
The facility failed to ensure compliance with Pre-admission Screening and Resident Review (PASRR) requirements for three residents with mental illness (MI) diagnoses and/or prescribed psychotropic medications. For these residents, the facility did not update PASRR Level I Screens to reflect changes in prescribed medications and did not submit timely PASRR Level II Screens when the residents remained in the facility beyond 30 days. Additionally, the facility did not obtain required county exemption forms (DHS form F-20822) upon admission for these residents. One resident with major depressive disorder and moderate dementia was admitted with a PASRR Level I Screen indicating MI and psychotropic medication use, but the screen was not updated when medications changed, and a Level II Screen was not submitted in a timely manner. Another resident, admitted with a diagnosis of acute respiratory failure but prescribed psychotropic medications for depression and anxiety, had a PASRR Level I Screen marked for MI and a 30-day hospital exemption, but the Level II Screen was not submitted until after the resident remained in the facility past 30 days. The required county exemption form was also not provided at admission. A third resident with a history of depression and OCD with skin picking was prescribed multiple psychotropic medications, but the PASRR Level I Screen did not reflect all current medications or MI diagnoses. The facility did not update the Level I Screen with new medications, did not submit a Level II Screen, and did not provide the county exemption form. Throughout the survey, the facility was unable to provide complete PASRR documentation or exemption forms for these residents despite multiple requests.
Failure to Provide Timely ADL Assistance and Restorative Care
Penalty
Summary
Two residents did not receive appropriate assistance with activities of daily living (ADLs) to maintain their highest practicable physical well-being. One resident, who had a perirectal abscess with a large residual wound following surgery, experienced delays in receiving timely toileting and incontinence care. This resident reported multiple instances where staff did not respond promptly to call lights, resulting in prolonged periods of sitting in urine or stool. Documentation and interviews revealed that staff sometimes failed to properly clean the resident after incontinence episodes, and on at least one occasion, a staff member declined to provide care, leaving the resident soiled until seen by outside wound clinic staff. The resident expressed discomfort, embarrassment, and concern that inadequate care could affect wound healing. Facility staff, including the Director of Nursing and Social Worker, were not consistently aware of these incidents or the related wound clinic notes. Another resident, with diagnoses including diabetes with polyneuropathy and repeated falls, was discharged from physical therapy with a recommendation for a restorative ambulation program. The program specified ambulation in the hallway once per shift with caregiver assistance. However, the resident's care plan did not include this ambulation or a restorative program, and staff were unaware of the walking schedule. Documentation showed that the resident was not consistently ambulated as recommended, with the majority of opportunities for ambulation marked as 'not applicable,' indicating the task did not occur. The resident expressed a desire to walk in the hallway with staff and reported not walking much since therapy ended. Facility policies required staff to provide timely responses to call lights, maintain residents' ADL abilities, and implement restorative nursing programs as indicated by assessments and therapy recommendations. In both cases, the facility failed to follow its own policies and procedures, resulting in residents not receiving necessary care and services to maintain their physical functioning and dignity.
Failure to Investigate Falls and Update Care Plans After Multiple Incidents
Penalty
Summary
Surveyors identified that the facility failed to ensure areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with a history of falls and cognitive impairment. Three residents with moderate cognitive impairment and significant medical conditions, including dementia, encephalopathy, osteoarthritis, diabetes, and hemiplegia, experienced multiple unwitnessed falls. Despite these incidents, the facility did not conduct thorough fall investigations to identify root causes or update the residents' care plans with new interventions to prevent further falls. The review of medical records revealed that after each fall, the facility did not consistently complete required neurological checks as outlined in their Fall Checklist. For several falls, neuro checks were missing or incomplete, and in some cases, the checks were performed at incorrect intervals. Additionally, the facility lacked a formal falls policy and relied on an undated Fall Checklist, which was not consistently followed by staff. The Director of Nursing confirmed that fall investigations did not identify root causes, care plans were not updated, and neuro checks were not thoroughly completed following unwitnessed falls. For one resident, five falls occurred over a two-week period without any new safety interventions being added to the care plan. Another resident experienced six falls, including incidents resulting in injury and hospital transfer, yet no new interventions were implemented, and one fall was not investigated at all. The facility's failure to follow fall procedures, update care plans, and complete post-fall assessments contributed to the deficiency identified by surveyors.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program based on direct observations, staff interviews, and record reviews involving two residents. One resident with a Foley catheter and multiple diagnoses, including Parkinson's disease and urinary retention, received perineal care from two CNAs who failed to perform hand hygiene between glove changes. The CNAs changed gloves multiple times during care, touched various clean and contaminated surfaces, and only performed hand hygiene after leaving the resident's room, contrary to facility policy. Another resident with a PEG tube and Parkinson's disease received pericare from an LPN who did not wash hands before donning gloves and did not wear a gown, despite the resident's use of an indwelling medical device. There was also no Enhanced Barrier Precautions (EBP) signage or PPE cart outside the resident's room, as required by facility policy. The LPN stated a misunderstanding of when gown use was necessary, believing it was only required if the resident was sick. Facility policies reviewed by surveyors clearly outlined the need for hand hygiene before and after glove use, the use of gowns and gloves during high-contact care activities for residents with indwelling devices, and the posting of EBP signage and availability of PPE. Both direct care staff and the Director of Nursing confirmed during interviews that the observed practices did not align with facility policies and procedures.
Failure to Complete Ordered Wound Care
Penalty
Summary
The facility failed to ensure wound care was completed as ordered for two residents, leading to a finding of immediate jeopardy. Resident 1, admitted for rehabilitation following surgery for Charcot's foot, had a physician's order for daily dressing changes. However, these dressing changes were not completed from May 22 to May 27, resulting in the discovery of maggots in the surgical wound by a registered nurse. The resident was subsequently transferred to the hospital for wound debridement and treatment with intravenous antibiotics. Resident 4 also experienced a lapse in wound care. The resident had a treatment order for a chronic ulcer on the right heel and midfoot, which required dressing changes three times a week. On June 14, the dressing change was not completed as ordered, and there was no documentation to indicate the treatment was performed. The Director of Nursing confirmed the missed treatment, and a subsequent dressing change revealed the previous dressing had not been changed since June 12. The facility's failure to adhere to the prescribed wound care regimen for these residents resulted in significant harm for Resident 1 and potential harm for Resident 4. The lack of documentation and follow-through on ordered treatments contributed to the deficiencies identified by the surveyors.
Removal Plan
- Initiated staff-wide education regarding wound care, neglect, TAR/Medication Administration Record (MAR) sign-outs, and resources.
- Initiated ongoing review with staff during huddles.
- Reviewed all current residents with wounds to ensure dressings were changed as ordered.
- Initiated a plan to complete dressing change audits to ensure all dressings are changed as ordered.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a sanitary manner, potentially affecting all 24 residents. During an initial kitchen tour, it was observed that the kitchen cooler contained items such as beef tips, cream of soup, and turkey soup that were not listed on the cooling log. The Dietary Manager confirmed that the facility's process is to document food cooling temperatures on the cooling log to ensure food is cooled safely with an approved cooling method. However, the leftover items in the cooler were stored without following the facility's cooling policy, which is a violation of the Wisconsin Food Code 2022 regarding cooling methods and time/temperature control for safety food. Additionally, the cleanliness of the kitchenettes was found to be inadequate. During a tour of the [NAME] Garden Home kitchenette, it was noted that the toaster contained crumbs, the refrigerator had multiple brown and white smudged food particles on the outside doors and handles, and the inside door of the vegetable crisper contained brown food particles, dried lettuce leaves, and onion skins. The bottom of the refrigerator and the bottom drawer of the freezer also contained various stains, discarded twist ties, and food particles. These unsanitary conditions were observed on two separate days, and the Dietary Manager confirmed that the kitchenettes should be cleaned daily and as needed by staff, which was not being done.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility did not ensure the resident environment for one resident was as free of accident hazards as possible. The facility failed to implement fall interventions contained in the resident's person-centered comprehensive care plan and medical record. The resident, who had severe cognitive impairment and multiple diagnoses including chronic diastolic heart failure and type 2 diabetes, experienced several falls resulting in injuries. Despite the care plan specifying interventions such as keeping the bed in the lowest position and placing a floor mat next to the bed, these measures were not consistently followed. Observations by the surveyor revealed the bed was not in the lowest position and the floor mat was not in place on multiple occasions. The resident's medical record indicated a history of falls, including incidents where the resident slid out of a wheelchair, fell from a recliner, and fell from bed, resulting in injuries such as a fractured left arm and femur. The Director of Nursing confirmed the interventions were required and acknowledged the failure to implement them. The lack of adherence to the care plan interventions contributed to the resident's repeated falls and injuries, highlighting a significant deficiency in ensuring a safe environment for the resident.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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