Edenbrook Of Green Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Bay, Wisconsin.
- Location
- 2961 St Anthony Dr, Green Bay, Wisconsin 54311
- CMS Provider Number
- 525307
- Inspections on file
- 20
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Edenbrook Of Green Bay during CMS and state inspections, most recent first.
A resident on hospice care with multiple serious diagnoses experienced a significant delay in receiving PRN morphine for pain, waiting approximately two hours after requesting the medication. Staff interviews and record review confirmed the delay was due to ineffective communication and failure to follow the facility's pain management policy, resulting in the resident's pain needs not being met promptly.
Surveyors found that an LPN administered medications to two residents without dating the medications upon opening, and left a medication cart unlocked and unattended with a resident's MAR visible during medication administration. Both the LPN and DON confirmed these actions did not follow facility policy.
A resident with type 2 diabetes was given the wrong insulin when an LPN administered Basaglar instead of the prescribed insulin aspart before a meal. The error was discovered when the LPN could not locate the correct insulin in the medication cart and the MAR inaccurately reflected the administration. The facility's medication administration policy requiring verification of the correct medication was not followed.
Staff did not adhere to infection control protocols, as an LPN failed to perform hand hygiene before and after medication administration for multiple residents, and a CNA used wash cloths prepared in an unsanitized sink for pericare. The facility's policy did not clearly specify procedures for pericare, contributing to inconsistent practices.
A resident with multiple health conditions activated their call light to request coffee, but the request was unmet for over an hour due to a change in procedure. The CNA turned off the call light without providing coffee, as dietary staff had instructed CNAs not to provide coffee directly. The dietary manager confirmed the new procedure required CNAs to request coffee via radio, which was not communicated to the resident. The DON stated call lights should remain on until needs are met.
The facility failed to consistently obtain daily weights for two residents with CHF and other conditions, as required by their care plans. Both residents had numerous missing weight records due to insufficient staffing to perform necessary transfers before breakfast. Staff interviews confirmed the lack of staffing as a reason for the missed weights, and the issue was acknowledged by the NP and DON.
The facility failed to follow care plans for two residents requiring mechanical lift transfers, resulting in unsafe practices due to inadequate staffing. Both residents, with specific medical conditions, were supposed to be assisted by two staff members during transfers, but often only one staff member was available. Staff interviews confirmed this ongoing issue, and the DON acknowledged the requirement for two staff members was not consistently met.
The facility failed to maintain accurate daily nursing staff postings, listing full shift hours even when staff worked partial shifts, and did not retain these postings for 18 months. Discrepancies were found between the postings and actual schedules, with the Nursing Home Administrator and Staffing Coordinator confirming the lack of updates for schedule changes.
The facility failed to maintain CPAP and BiPAP machines for four residents, neglecting to replace filters as per manufacturer guidelines. Residents with conditions like COPD and sleep apnea had machines with dirty or missing filters, compromising their respiratory care. The DON confirmed the lack of maintenance and supplies for filter replacement.
The facility did not adhere to prescribed diet serving sizes for residents requiring therapeutic and mechanically altered diets. A resident on hemodialysis was not served the correct double protein portion, and others with conditions like dysphagia and cerebral palsy received smaller portions than required. The Dietary Manager confirmed that meal tickets and care plans were not updated, leading to incorrect servings.
A resident was observed with medication at their bedside without a self-administration assessment or physician's order. The resident, who had intact cognition, confirmed self-administering the medication. Facility policy requires a nurse's assessment and a physician's order for self-administration, and medications should be secured. The DON confirmed the lack of required documentation and ordered the medication's removal.
A resident with intact cognition and a history of giving cigarettes to others was observed with smoking materials in their wheelchair, contrary to the facility's policy requiring such items to be stored at the nurses' station. Despite being assessed as needing the facility to store their smoking materials, the resident was allowed to keep these items, highlighting a failure to enforce the smoking policy and ensure a safe environment.
The facility failed to prevent urinary tract infections for two residents with indwelling catheters by not adhering to its catheter care policies. Observations showed that the catheter drainage bags were uncovered and in contact with the floor, contrary to the facility's guidelines. Despite the Director of Nursing's expectations for staff to cover the bags and maintain proper hygiene, a CNA was observed not addressing the improper positioning of a catheter bag.
The facility failed to properly label and store medications for three residents, leading to discrepancies in medication management. A nurse administered insulin with a dosage discrepancy, and another resident received eye drops without an open date. Additionally, wound care solutions were improperly stored at a resident's bedside, contrary to facility policy.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with wounds and another with an indwelling catheter. Despite the facility's policy requiring EBP for such conditions, there were no EBP signs on the residents' doors, leading to staff not wearing necessary PPE during care. The Director of Nursing confirmed the oversight, highlighting a lapse in infection control measures.
A resident at the facility consented to receive the PCV20 vaccine, but it was not administered due to a staff oversight. The resident, who had intact cognition, signed a consent form, but the vaccine was not given. The ADON acknowledged the mistake, stating the form was likely filled out incorrectly, and confirmed that the vaccine should have been administered per facility policy and CDC guidelines.
Delay in PRN Pain Medication Administration for Hospice Resident
Penalty
Summary
A deficiency occurred when a resident receiving hospice services, with diagnoses including lung cancer, brain cancer, COPD, and generalized anxiety disorder, did not receive prescribed PRN morphine for pain in a timely manner. The resident, who was cognitively intact, reported waiting approximately two hours for pain medication after requesting it. Staff interviews confirmed that there was a delay in administering the medication, as communication between nurses and CNAs was not effective, leading to the resident's request being overlooked until a CNA followed up. Documentation showed the resident had ongoing pain and discomfort, including issues with constipation, but the pain medication was not provided promptly as ordered. The facility's pain management policy required timely assessment and administration of pain medication, but this was not followed in the incident. The Assistant Director of Nursing was not initially aware of the delay, and the nurse responsible did not report the incident as required. The event was later identified through interviews and record review, confirming that the resident's pain management needs were not met according to policy and physician orders.
Failure to Properly Label and Secure Medications and MARs
Penalty
Summary
Surveyors observed that staff failed to properly label and store medications for two residents during medication administration. Specifically, an LPN administered timolol maleate ophthalmic solution to one resident and Basaglar KwikPen insulin to another without either medication being dated upon opening, as required by facility policy. The eye drops had been opened and dispensed over two months prior, and the insulin pen had also been dispensed several days before the observation, but neither contained an open date. The LPN confirmed during interviews that the medications were not dated as required. Additionally, the LPN left a medication cart unlocked and unattended in the hallway while administering medication to a third resident. The computer on top of the cart, displaying the resident's Medication Administration Record (MAR), was also left open and visible. The cart was not within the LPN's line of sight during this time. Both the LPN and the Director of Nursing acknowledged during interviews that the cart should have been locked and the medications and MAR secured according to facility policy.
Incorrect Insulin Administered Due to Medication Verification Failure
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes and morbid obesity, who was cognitively intact, received the wrong type of insulin during medication administration. The resident had a physician's order for insulin aspart to be administered before meals for hyperglycemia, but instead, an LPN administered 5 units of Basaglar KwikPen, a long-acting insulin, in error. The medication administration record (MAR) incorrectly documented that insulin aspart had been given, and the LPN was unable to locate the prescribed insulin aspart in the medication cart, finding only Basaglar and insulin lispro pens available. The facility's policy required verification of the right medication, dose, route, time, and resident identity before administration, but these procedures were not followed in this instance. The LPN did not realize the error at the time of administration and only became aware after review and questioning by the surveyor. The incident was confirmed through observation, record review, and staff interviews, with the LPN acknowledging the mistake and the MAR's inaccuracy.
Failure to Follow Infection Control Practices During Medication Administration and Pericare
Penalty
Summary
Staff failed to follow proper infection prevention and control practices for four residents, as observed by surveyors. An LPN did not perform hand hygiene before preparing or after administering medications to three residents, despite the facility's policy requiring hand hygiene before donning gloves and after removing them. The LPN confirmed during an interview that hand hygiene was not completed between residents during medication preparation and administration. The Infection Preventionist also indicated that hand hygiene should have been performed between residents, either by washing hands or using alcohol-based sanitizer. Additionally, a CNA was observed placing clean wash cloths in an unsanitized sink, running water over them, wringing them out, and hanging them over the side of the sink before using them to provide pericare to a resident. The CNA acknowledged that the sink was not sanitized prior to use and stated that a basin is only used for in-bed care, not in the bathroom. The Director of Nursing confirmed that staff should use a basin or wipes for pericare, in line with facility policy. However, the facility's Activities of Daily Living policy, which was the only pericare policy available, did not specify the use of a basin or wipes during pericare.
Resident's Call Light Request for Coffee Unmet in Timely Manner
Penalty
Summary
The facility failed to ensure timely assistance for a resident's request, resulting in a deficiency. On the morning of February 26, 2025, a resident with diagnoses including spinal stenosis, type 2 diabetes mellitus, COPD, anxiety, and chronic pain syndrome, activated their call light at 6:46 AM to request a cup of coffee. The resident, who had intact cognition and required setup assistance for eating, was observed by the surveyor to have their call light turned off by a CNA at 7:12 AM without receiving the requested coffee. The resident expressed that it was common to wait a long time for staff to respond to call lights, sometimes up to two hours. The CNA confirmed turning off the call light and not providing coffee due to instructions from dietary staff that CNAs could not provide coffee directly. The dietary staff had recently changed the procedure, requiring CNAs to use a radio to request coffee from the kitchen, as a carafe of coffee was no longer provided to the unit. The dietary manager confirmed this change and indicated that coffee could be sent ahead of meal trays if requested. The Director of Nursing stated that a resident's call light should remain on until their need is met, highlighting a lapse in communication and procedure adherence that led to the resident's unmet request.
Failure to Consistently Obtain Daily Weights for Residents
Penalty
Summary
The facility failed to provide necessary care and treatment to maintain the highest practicable well-being for two residents, R7 and R10, by not consistently completing daily weights as ordered. R7, who has diagnoses including congestive heart failure (CHF) and diabetes, had 44 missing daily weights from 11/10/24 to 2/25/25. R7's care plan required daily weights to monitor fluid volume due to CHF and venous insufficiency, but these were often missed due to insufficient staff to perform the necessary two-assist transfer before breakfast. R7 confirmed that weights were frequently missed, and staff interviews corroborated the lack of staffing as a reason for the missed weights. Similarly, R10, with diagnoses of high blood pressure and chronic venous insufficiency, had 64 missing daily weights from 10/9/24 to 2/26/25. R10's care plan also required daily weights to monitor for significant changes, but these were not consistently obtained due to staffing shortages. Interviews with staff, including a Registered Nurse, Licensed Practical Nurse, and Certified Nursing Assistant, confirmed that the lack of staff made it difficult to complete daily weights for residents requiring two staff for mechanical lift transfers. The Nurse Practitioner and Director of Nursing acknowledged the issue, noting that weights were missed and that staff needed prompting to follow physician orders.
Inadequate Staffing Leads to Unsafe Transfer Practices
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R9 and R10, by not consistently following their care plans for mechanical lift transfers. R9, who has quadriplegia, diabetes, and hypotension, was supposed to be transferred with the assistance of two staff members using a full-body (Hoyer) lift. However, R9 reported that there were instances when only one staff member attempted to assist with the transfer, leading to delays in care due to insufficient staffing. R9 expressed feeling unsafe during these attempts and refused the transfer when only one staff member was present. Similarly, R10, who has high blood pressure and chronic venous insufficiency, required assistance from two staff members for transfers using a sit-to-stand (EZ Stand) lift. Despite this requirement, R10 reported that only one staff member assisted with the transfers. Interviews with staff, including an LPN and a CNA, confirmed that mechanical lift transfers were often conducted with only one staff member due to staffing shortages. The Director of Nursing acknowledged that the care plans for R9 and R10 required two staff members for safe transfers, which was not consistently adhered to.
Inaccurate and Incomplete Nursing Staff Postings
Penalty
Summary
The facility failed to maintain accurate and complete daily nursing staff postings, which had the potential to affect all 68 residents. The postings did not reflect actual hours worked by staff, as they included full shift hours even when staff worked partial shifts. For instance, the posting for the 10:00 PM to 6:00 AM shift inaccurately indicated that three CNAs worked a total of 22.5 hours, despite some CNAs only working partial shifts. Additionally, the facility did not retain these postings for the required 18 months, instead providing printed versions without edits for staffing changes. The surveyor's review of the facility's nursing staff postings and schedules revealed discrepancies, such as listing staff under full shift rows when they only worked partial shifts. The Nursing Home Administrator confirmed that the data for postings was pulled from a computer program and that original postings were not retained. The Staffing Coordinator also confirmed that postings were not updated to reflect schedule changes, such as call-ins or partial shifts. This lack of accurate and retained documentation was identified through observations, staff interviews, and record reviews.
Failure to Maintain CPAP/BiPAP Machines
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents who required CPAP or BiPAP machines. The facility did not adhere to the manufacturer's instructions and its own policy regarding the cleaning and maintenance of these machines. Specifically, the facility did not replace the filters on the CPAP and BiPAP machines as recommended by the manufacturer, which is crucial for maintaining the effectiveness and hygiene of the equipment. Resident 3, who had diagnoses including COPD, chronic respiratory failure, and obstructive sleep apnea, used a CPAP machine regularly. However, the filter on the machine was observed to be dark and dirty, indicating it had not been changed as required. Resident 49, with severe cognitive impairment and a history of sleep apnea, also had a BiPAP machine with a filter that appeared dirty and contained dust and hair. Both residents expressed concerns about the cleanliness of their machines, and there were no orders in place to check and change the filters. Similarly, Resident 22, who had chronic respiratory failure and used a BiPAP machine, and Resident 27, who used a CPAP machine, also had issues with filter maintenance. The filters on their machines were observed to be unsanitary, and in the case of Resident 27, the CPAP machine was missing a filter entirely. The Director of Nursing confirmed the lack of proper maintenance and the absence of supplies to change the filters, acknowledging the deficiency in care provided to these residents.
Failure to Follow Prescribed Diet Serving Sizes
Penalty
Summary
The facility failed to ensure that menu serving sizes were followed for therapeutic and mechanically altered diets for five residents. Specifically, the staff served smaller portions than indicated on the extended menu for residents who required double protein and those prescribed mechanically altered diets. The facility's policy required that all diets be prescribed by the attending physician and reviewed by a dietitian for accuracy and therapeutic goals. However, the surveyor observed that the dietary staff did not adhere to these requirements, leading to discrepancies in the serving sizes provided to the residents. Resident 69, who was dependent on hemodialysis and required a double protein diet, was not served the correct portion size as per the dietitian's assessment. Similarly, residents with diagnoses such as dysphagia, malignant neoplasm of the tonsil, and cerebral palsy, who required mechanically altered diets, were served with a smaller scoop than specified. The Dietary Manager confirmed that the meal tickets and care plans were not updated to reflect the correct diet orders, resulting in the residents not receiving the appropriate portion sizes as per their dietary needs.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R54, had a self-administration of medication assessment or a physician's order to self-administer medication. On two separate occasions, a surveyor observed medication, specifically a bottle of 12% ammonium lactate lotion, left at R54's bedside. R54, who had intact cognition as indicated by a BIMS score of 13 out of 15, confirmed self-administering the lotion without staff assistance. However, the resident's medical record did not contain the necessary documentation for self-administration of medication. The facility's policy requires a licensed nurse to complete a screen to determine factors impacting safe medication administration and a physician's order for self-administration. Additionally, medications to be self-administered should be secured in a locked area or stored in the medication cart. The Director of Nursing confirmed that R54 did not have the required assessment or order and acknowledged that medication should not be stored on a resident's bedside table. Consequently, the medication was removed from R54's room by a registered nurse as per the Director of Nursing's instructions.
Failure to Enforce Smoking Policy for Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident known to smoke. The resident, who had intact cognition and was assessed as needing the facility to store their smoking materials, was observed with cigarettes and a lighter in their wheelchair. This was contrary to the facility's Smoking and E-Cigarettes Policy, which required all smoking materials to be stored at the nurses' station and prohibited in resident rooms. Despite the policy and the resident's smoking care plan stating that smoking materials should be stored with staff, the resident was allowed to keep these items on their person. The deficiency was further highlighted when the resident was observed self-propelling their wheelchair with smoking materials in the cup holder, and the Assistant Director of Nursing confirmed that residents were not supposed to keep cigarettes and lighters. The Director of Nursing acknowledged that the resident had a history of giving cigarettes to other residents and confirmed that the resident was not supposed to have smoking materials on their person. Despite this, the resident was again observed with a lighter in their wheelchair cup holder, indicating a failure to enforce the facility's smoking policy and ensure the resident's environment was free from potential hazards.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for two residents with indwelling catheters. The facility's policies required catheter bags to be covered and not in contact with the floor to prevent infection. However, observations revealed that the catheter drainage bags of two residents, R47 and R49, were uncovered and in contact with the floor. R47, who had intact cognition, was observed on two occasions with the catheter bag visible from the hallway and touching the floor. Similarly, R49, who had severely impaired cognition, was observed with the catheter bag on the floor, and an empty basin nearby, which the resident stated staff sometimes used to place the bag. The Director of Nursing confirmed that catheter bags should not be on the floor due to infection control issues and that staff were expected to cover the bags for dignity. Despite this, a Certified Nursing Assistant was observed leaving R49's room without addressing the catheter bag's position on the floor. The facility's failure to adhere to its catheter care policies and procedures contributed to the deficiency in preventing urinary tract infections for these residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for three residents, leading to deficiencies in medication management. For one resident, a nurse administered Basaglar insulin with a dosage discrepancy between the medication bag label and the Medication Administration Record (MAR). The nurse acknowledged that the label should have been updated, and the Director of Nursing (DON) confirmed the label should reflect the correct dose. Another resident received Systane Ultra Ophthalmic Solution without an open date on the bottle or carton, which the nurse and DON verified should have been labeled with the opening date. Additionally, a third resident had wound care treatment solutions, including Dakin's solution, Vashe wound therapy solution, and acetic acid, stored on their bedside table, contrary to the facility's policy. The resident confirmed the bottles were used daily for wound cleaning, and the DON verified that these medications should not be stored at the bedside without an order. The DON instructed staff to remove the medications from the resident's room, indicating a lapse in adherence to medication storage policies.
Inadequate Infection Control Measures for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for two residents, R51 and R54. R51, who had wounds requiring care, was not placed on EBP, and there was no EBP sign on or near the entrance to R51's room. Despite having wounds on the left leg and abdomen, which required daily dressing changes, the necessary precautions were not communicated to staff, as confirmed by the Director of Nursing (DON). The absence of an EBP sign meant that staff were likely unaware of the need to don personal protective equipment (PPE) when providing care to R51, contrary to the facility's policy. Similarly, R54, who had an indwelling catheter, was not initially placed on EBP, and there was no EBP sign on or near the room entrance. During an interview, a Certified Nursing Assistant (CNA) acknowledged that R54 should have been on EBP and that staff should have been wearing PPE during care. The DON confirmed that R54 should have been on EBP and that the Infection Preventionist should ensure compliance with the facility's EBP policy. The oversight in implementing EBP for these residents indicates a lapse in the facility's infection control measures.
Failure to Administer PCV20 Vaccine After Resident Consent
Penalty
Summary
The facility failed to administer the PCV20 vaccine to a resident who had consented to receive it. The resident, who had intact cognition and no activated power of attorney for healthcare, signed a consent form on October 11, 2023, indicating their desire to receive the PCV20 vaccine. However, the medical record did not show that the vaccine was administered. During an interview, the resident confirmed that they had signed the consent form but had not received the vaccine. The Assistant Director of Nursing (ADON) acknowledged that the consent form was likely filled out incorrectly by staff, leading to the oversight. The ADON confirmed that if consent was received for a vaccine offered by the facility, it should have been administered. The Nursing Home Administrator also stated that staff are expected to offer vaccines per CDC recommendations and the facility's policy, and that the resident should have received the vaccine if they consented to it.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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