Edenbrook Sheboygan
Inspection history, citations, penalties and survey trends for this long-term care facility in Sheboygan, Wisconsin.
- Location
- 3014 Erie Ave, Sheboygan, Wisconsin 53081
- CMS Provider Number
- 525568
- Inspections on file
- 45
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Edenbrook Sheboygan during CMS and state inspections, most recent first.
The facility failed to consistently complete timely post-fall assessments with updated VS and to implement care-planned fall-prevention interventions for four residents with dementia, hemiplegia, Parkinson’s disease, diabetes, and other comorbidities. After unwitnessed falls, post-fall assessments were delayed or documented using VS obtained many hours earlier, and required tools such as gripper socks, reachers, and a reminder sign to call for assistance were not consistently in place or within reach. Staff interviews revealed inconsistent understanding of post-fall monitoring practices, including differences in whether standard neuro checks and VS were performed after falls.
The facility did not ensure that residents and their legal representatives were consistently invited to and involved in care conferences as required by its own policy. Over the course of a year, three residents with moderate cognitive impairment and significant medical conditions, including Parkinson’s disease, dementia, stroke history, hemiplegia, type 2 DM, mood disorder, and CKD, had only one or two documented care conferences each, with no evidence that additional quarterly conferences were offered or declined or that their Guardian/POAHC were invited. A POAHC reported not being invited to a care conference for almost a year despite wanting one. The SW acknowledged not consistently using the Care Conference UDA, and the NHA confirmed that care conferences should be attempted at least quarterly and that the UDA should be used per policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after staff failed to follow elopement procedures, including responding to door alarms and conducting a head count. The resident exited through an alarmed stairwell door, which was silenced by a visitor, and was later found by police in a hospital parking lot. Staff were unaware of the resident's absence until notified by authorities.
The facility did not consistently record food and beverage temperatures for multiple meals, with logs showing missing or incomplete entries and some beverages served above the required temperature threshold. Staff interviews confirmed inconsistent practices and lack of a formal policy, resulting in unsafe food storage and preparation.
A resident with severe cognitive impairment eloped from the facility and experienced two falls in one day. The Guardian was not promptly notified of the elopement or the second fall, only being informed after the resident's hip fracture was discovered and hospital transfer was required. Facility staff failed to follow notification policies for changes in condition and incidents affecting the resident.
A resident with severe cognitive impairment and multiple comorbidities experienced two falls in one day. After the second fall, the resident, who complained of hip pain and had a pending X-ray order, was transferred from the floor to bed using Hoyer slings before a comprehensive assessment was completed, contrary to facility policy. Staff and administrator interviews confirmed the resident was moved prior to full evaluation, despite policy requiring assessment for pain and injury before transfer.
A resident with severe cognitive impairment and multiple medical conditions was administered antipsychotic medication without documented attempts at non-pharmacological interventions, as required by facility policy. Staff did not consistently implement or document behavioral strategies before using medications, and the care plan lacked specific guidance for antipsychotic use.
Surveyors found that dietary staff failed to maintain required dishwashing temperatures and did not follow proper hand hygiene protocols during meal service. The dish machine consistently operated below the minimum wash temperature, and staff did not rewash dishes to meet standards. Additionally, dietary aides handled food and touched contaminated surfaces without changing gloves or washing hands, contrary to facility policy and state food code.
A resident with a legal Guardian and multiple diagnoses, including traumatic brain injury and mood disorder, did not have the required court-ordered protective placement documentation in their medical record. Despite communication between facility staff and the Aging and Disability Resource Center, the necessary guardianship documents were not obtained or filed as required by state statute.
The facility did not notify the State Long-Term Care Ombudsman of hospital and ED transfers for two residents, as required by policy. One resident's hospital transfer and another resident's two ED transfers were omitted from the monthly reports, with staff confirming these events were not reported due to oversight and lack of awareness of notification requirements.
Two residents with significant cognitive and psychiatric conditions received new or changed orders for psychotropic medications, including antipsychotics and antidepressants, without the facility updating their PASRR Level I Screens or initiating required Level II evaluations. Staff confirmed awareness of these changes but did not complete the necessary PASRR updates.
A resident with dementia, Parkinson's disease, and a history of multiple falls was not consistently provided the supervision and assistance devices outlined in their care plan. Despite documented needs for limited assist with transfers, supervision during toileting, and a low bed position, staff allowed the resident to ambulate and transfer independently, and the bed was not kept in a low position. Staff interviews revealed inconsistent adherence to the care plan, contributing to repeated unwitnessed falls.
Staff failed to follow infection control protocols for two residents on transmission-based precautions. In one case, a staff member entered a resident's room on droplet precautions without required PPE, and in another, the ADON administered IV medication to a resident on enhanced barrier precautions without wearing a gown, contrary to facility policy.
A resident with multiple health conditions developed a pressure injury due to the facility's failure to provide timely and appropriate wound care. The wound was initially misclassified, delaying necessary interventions, and staff did not correctly transcribe treatment orders, leading to inadequate care. Observations showed the resident was not consistently using required heel boots, resulting in the wound progressing to a stage 4 pressure injury.
A resident with serious health conditions was transferred to the hospital by their POAHC without the facility notifying the resident's physician, as required by policy. The facility only informed hospice staff, which was insufficient according to the Nursing Home Administrator.
The facility did not thoroughly investigate altercations between two residents with severe cognitive impairments. Despite initial responses, there was a lack of documentation for required 15-minute checks on one resident, indicating a deficiency in following abuse prevention protocols.
The facility failed to consistently document oral care for three residents, as required by their policy. One resident with moderately impaired cognition had two days without documented oral care, while another resident with a history of stroke had one day without documentation. A third resident with severely impaired cognition had two days marked as not applicable without explanation. The DON confirmed that undocumented care is considered not done.
The facility failed to provide appropriate catheter care for two residents. One resident's catheter drainage bag was found on the floor, contrary to CDC guidelines, and the facility's policy lacked guidance on proper catheter positioning. Another resident had no catheter care orders or documentation upon admission, and their care plan was delayed. The facility had identified similar issues in a mock survey, but staff education was pending.
A resident with multiple health conditions, including multiple sclerosis and a pressure ulcer, was unable to activate their call light to request assistance due to a malfunction. The issue was confirmed by a surveyor and a CNA, who then reported it for maintenance. The facility's policy requires call lights to be operational at all times.
A resident's wheelchair was found to be visibly dirty, with dried debris and greasy dirt, indicating a failure to maintain a clean, comfortable environment. The NHA stated that night shift CNAs were responsible for cleaning wheelchairs on bath days, but there was no documentation of this task being completed. The resident, who had intact cognition, was unaware if their wheelchair had been cleaned and expressed a desire for it to be cleaned.
A resident with a history of anemia and diabetes mellitus experienced a fall in a facility, resulting in a contusion and shoulder pain. Despite the facility's policy requiring immediate notification of the physician and responsible parties, staff failed to promptly notify the resident's primary care physician or send the resident to the ER. Instead, they contacted an on-call nephrologist from a different medical group, leading to a delay in care. The facility's failure to adhere to its policies and ensure timely medical intervention resulted in a deficiency.
A resident with severe cognitive impairment and a history of mental health issues was left unsupervised, allowing them to crawl out of a second-story window with the intent to jump. Despite a recommendation for 1:1 supervision, the facility failed to ensure adequate supervision, leading to a finding of immediate jeopardy.
The facility failed to properly store, label, and date medications for ten residents, with insulin left unrefrigerated and medication carts unlocked. The refrigerator in the medication storage room was not maintained at the required temperature, and treatment carts contained expired and unlabeled treatments. The Director of Nursing confirmed the facility's failure to track temperature issues and ensure proper storage practices.
Failure to Provide Consistent Post-Fall Monitoring and Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, consistent implementation of fall-prevention interventions, and complete post-fall assessments, including timely vital signs (VS), for four residents. Facility policy dated 1/21/26 required individualized fall-prevention interventions to be implemented consistently and post-fall monitoring with documentation of the resident’s condition at least every shift for 72 hours, including VS and other relevant clinical findings. Despite this, multiple post-fall assessments for several residents lacked updated VS, and some required fall-prevention interventions were not implemented as care-planned. One resident with dementia, hypertension, anxiety, right-sided hemiplegia, and severe cognitive impairment (BIMS 0/15) was at high risk for falls and at risk for bleeding and excessive bruising related to anticoagulant therapy. This resident had an unwitnessed fall in the room on 1/10/26 and was found on the floor, incontinent of urine and unable to report what happened. The fall investigation identified impulsive behavior, decreased safety awareness, and cognitive impairment as root causes, and an immediate intervention was added to ensure gripper socks were on both feet. However, the care plan revised on 1/28/26 did not contain the gripper sock intervention. Post-fall assessments did not begin until approximately 48 hours after the fall, and three of eight documented post-fall assessments used VS obtained many hours earlier rather than updated VS at the time of assessment. Another resident with Parkinson’s disease, anxiety, depression, chronic pain, and moderate cognitive impairment (BIMS 11/15) was care-planned as high risk for falls due to Parkinson’s disease, neuropathy, and dementia with impaired safety awareness. This resident had multiple unwitnessed falls in the room related to impaired safety awareness and attempts to self-transfer or reach for items. For one fall, a CNA Fall Investigation form, which should have included last interaction, items within reach, toileting plan, care plan, and areas for improvement, was not completed. Across three separate falls, ten of thirty-one post-fall assessments did not include updated VS, instead relying on VS taken several hours to more than a day earlier. A third resident with left-sided hemiplegia, dementia, diabetes, mood disorder, and moderate cognitive impairment (BIMS 10/15) was at moderate risk for falls due to left-sided weakness and impaired safety awareness. This resident experienced two unwitnessed falls in the room on the same day while reaching for items. An intervention was added to have two reachers within reach in the room. However, three of ten post-fall assessments lacked updated VS, using earlier readings instead. During observation, the resident was in a wheelchair in the middle of the room with both reachers placed against walls (one by the bed and one on top of supplies near the TV), and the resident demonstrated inability to reach either device. The DON confirmed the reachers were not within reach and stated they should be within reach at all times. A fourth resident with vascular dementia, diabetes, stroke, and moderate cognitive impairment (BIMS 10/15) was at moderate risk for falls due to weakness and dementia. This resident had an unwitnessed fall in the room and could not recall the event. An intervention for a reminder sign to call for assistance before getting up was added to the care plan. Three of ten post-fall assessments did not include updated VS, instead using VS taken several hours earlier. During observation, the resident was seated in the room and no reminder sign was present. The DON later observed the room and stated the sign had been hung near the calendar but must have been taken down or misplaced and was unsure how long it had been missing. Staff interviews showed inconsistent understanding of post-fall monitoring practices: one RN stated the practice was to check residents once or twice per shift without neurological checks, while an LPN stated the facility still did standard post-fall neurological checks with VS at each assessment, and the DON stated policy required assessment once per shift unless otherwise ordered, with additional provider notification for residents on anticoagulants.
Failure to Involve Residents and Representatives in Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure residents and/or their legal representatives were able to participate in the development and implementation of person-centered plans of care, as required by facility policy. The Care Conference policy, revised 6/20/23, states that residents and/or responsible parties are to receive advance communication of scheduled care conferences and that the Interdisciplinary Team (including MDS, nursing, therapy, activities, social services, and dietary) will review key clinical areas and complete a Care Conference User Defined Assessment (UDA) for attendance and discussion tracking. Record review showed that one resident with Parkinson’s disease, dementia, OCD, anxiety, depression, osteoarthritis, and chronic pain, with a BIMS score of 11 (moderate cognitive impairment) and a court-appointed Guardian, had only two care conferences documented in the last year, with no evidence that additional quarterly conferences were offered or declined, and no documentation that the Guardian was invited to quarterly care conferences. Another resident with dementia, left-sided hemiplegia, type 2 diabetes, mood disorder, and chronic kidney disease, with a BIMS score of 10 and an activated POAHC, had only one care conference documented in the last year, with no indication that other quarterly conferences were offered or declined or that the POAHC was invited. A third resident with vascular dementia, history of stroke, and type 2 diabetes, also with a BIMS score of 10 and an activated POAHC, had only one care conference documented in the last year. The POAHC for this resident reported not being invited to a care conference for almost a year, had never refused a care conference, and wanted a conference to discuss the resident’s care. The Social Worker stated that care conference timing is personalized and acknowledged not consistently using the Care Conference UDA per policy, and the Nursing Home Administrator confirmed that care conferences should be attempted at least quarterly and upon request, and that the Social Worker should be using the Care Conference UDA as required by facility policy.
Failure to Supervise and Prevent Elopement for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, was care planned for elopement risk and had a WanderGuard device in place. On the day of the incident, the resident made multiple attempts to exit the unit and was redirected by staff, but no increased supervision was implemented despite the resident's persistent exit-seeking behavior. During a period of high activity with many visitors present, the resident was able to exit the facility through a second-floor stairwell door that was equipped with a functioning alarm. A family member of another resident silenced the alarm and informed staff, who were occupied with other residents and did not follow the facility's elopement procedures. Specifically, staff did not conduct a head count or check the perimeter after being notified of the alarm. As a result, staff were unaware that the resident had left the facility until the police notified them after finding the resident 0.6 miles away in a hospital parking lot, inadequately dressed for the cold weather. Interviews and record reviews revealed that agency staff working that shift had not received orientation or training on the WanderGuard system, and family members had access to alarm codes, allowing them to silence alarms. The facility's investigation was unable to determine exactly how the resident eloped without staff knowledge, but it was clear that staff failed to follow established elopement procedures, including immediate response to alarms, perimeter checks, and head counts. This failure resulted in a finding of immediate jeopardy due to the reasonable likelihood for serious harm.
Removal Plan
- Initiated checks for R1 and updated R1's care plan.
- Changed alarm keypad codes to ensure family members/visitors do not have access to codes or a means to clear alarms.
- Instructed maintenance staff to change the codes at intervals.
- Educated staff on the facility's elopement policy, door alarm system, and new procedure for elevator/door codes.
- Completed elopement drills and tested both systems.
Failure to Maintain Safe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe manner, as evidenced by incomplete and missing food and beverage temperature logs for multiple dates across both the second and third floor dining rooms. Surveyors observed that meal and beverage temperatures were not consistently recorded for breakfast, lunch, or dinner, with entire days and weeks lacking documentation. Additionally, some temperature logs were undated and contained multiple missing entries. During observation, beverage temperatures prior to serving were found to be above the required 41 degrees Fahrenheit, with apple juice and milk measured at 48 to 49 degrees Fahrenheit. Interviews with dietary staff revealed that it was the responsibility of aides present at each meal to record food and beverage temperatures, but this was not consistently done, particularly for dinner service. The dietary aide present confirmed the expectation to record temperatures for all meals and beverages, but acknowledged gaps due to part-time staffing. The Nursing Home Administrator confirmed that staff education on temperature logging had been provided previously, but also stated that the facility did not have a formal policy regarding food temperatures, relying instead on the Wisconsin Food Code.
Failure to Notify Guardian of Resident Elopement and Multiple Falls
Penalty
Summary
The facility failed to notify a resident's court-appointed Guardian of significant changes in the resident's condition and incidents requiring treatment alteration. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia, PTSD, delirium, and anxiety, eloped from the facility without staff knowledge. Staff last observed the resident in the afternoon, but only became aware of the elopement when police arrived after finding the resident at a nearby hospital. The Guardian was not informed of the elopement until several days later, learning of the incident first from the resident's family and Adult Protective Services, rather than from facility staff as required by policy. Additionally, the resident experienced two falls on the same day. After the first fall, the Guardian was notified and an X-ray was ordered due to complaints of hip pain. However, following a second fall later that evening, the Guardian was not informed of this additional incident. The Guardian was only contacted after the X-ray revealed a hip fracture and consent was needed for hospital transfer. Interviews confirmed that staff did not notify the Guardian of the second fall, despite facility policy requiring notification of all changes in condition.
Resident Transferred After Fall Without Required Assessment
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, experienced two falls in one day. After the second fall, the resident was found sitting on the floor, complaining of pain in the right thigh/hip. According to the facility's Post Fall policy, staff are required to conduct a comprehensive evaluation, including assessment for symptoms such as numbness, tingling, or pain, before moving a resident after a fall. If certain symptoms are present, the policy directs staff not to move the resident and to notify a provider or call 911. In this incident, the LPN assisted the resident to a supine position and, with the help of other staff, transferred the resident from the floor to the bed using Hoyer slings before completing a full physical assessment. The nursing progress note and staff interviews confirm that the resident was moved prior to a comprehensive assessment, despite the resident's complaint of hip pain and a pending X-ray order from an earlier fall. The Nursing Home Administrator stated that the facility's policy requires vital signs and pain assessments before transferring a resident unless there are obvious signs of severe injury. However, the administrator was unaware that the injury information pertained to the first fall and that a second fall had occurred. The transfer of the resident from the floor to the bed was performed while the resident was experiencing pain and before the results of the pending X-ray were available, which was not in accordance with the facility's policy.
Failure to Implement Non-Pharmacological Interventions Prior to Antipsychotic Use
Penalty
Summary
A deficiency occurred when the facility failed to prevent the use of unnecessary psychotropic medications for a resident with severe cognitive impairment and multiple medical diagnoses, including cancer, anxiety disorder, and depression. The facility administered antipsychotic medication (haloperidol) to the resident without first implementing or documenting non-pharmacological interventions to address the resident's behaviors, as required by facility policy. The medical record lacked evidence of behavioral assessments, documentation of specific behaviors or symptoms, and the resident's response to non-pharmacological interventions prior to the administration of antipsychotic medication. The resident was bedbound, receiving hospice services, and had a history of restlessness, agitation, and calling out. Staff interviews revealed that the resident was not regularly checked on, did not use a call light, and was not on frequent checks. Although the care plan included interventions such as sensory activities, companionship, and music, these were not consistently implemented or documented. Staff primarily addressed restlessness by offering snacks, water, and repositioning, but there was no evidence that these or other non-pharmacological strategies were attempted or evaluated before resorting to medication. The facility's records showed that the resident received both lorazepam and haloperidol for agitation and restlessness, with medication orders being changed due to perceived ineffectiveness. However, there was no documentation of the required assessments or monitoring for side effects, and the care plan did not include a specific plan for antipsychotic medication use. Staff interviews confirmed that non-pharmacological interventions were not consistently provided or documented, and the facility did not obtain a risks versus benefits statement regarding getting the resident out of bed, despite conflicting information about the resident's preferences and family wishes.
Deficient Food Sanitation and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure that food was prepared and served in a safe and sanitary manner, as evidenced by improper dishwashing temperatures and inadequate hand hygiene practices among dietary staff. During multiple observations, the facility's American Dish Service model ADC-44 multi-tank conveyor dish machine did not reach the minimum wash temperature required by both the manufacturer's data plate and the Wisconsin Food Code. Recorded wash temperatures ranged from 150 to 158 degrees F, below the required minimum of 159 degrees F. Despite these substandard temperatures, staff did not rewash dishes to meet the necessary standards, and maintenance staff incorrectly advised that temperatures above 150 degrees F were sufficient. Additionally, dietary staff did not follow proper hand hygiene protocols during meal service. One dietary aide donned gloves without washing hands, touched various surfaces and ready-to-eat foods with the same pair of gloves, and continued serving food with visibly soiled gloves without changing them or cleansing hands. Another dietary aide used hand sanitizer before donning gloves but then touched multiple contaminated surfaces, including a thermometer, sanitizing wipes, and cabinet handles, and scratched their head with soiled gloves before handling food, again without changing gloves or performing hand hygiene. These practices were observed during meal service and confirmed by the Dietary Manager and Corporate Dietitian, who acknowledged that staff failed to adhere to both facility policy and state food code requirements. The deficiencies had the potential to affect nearly all residents in the facility, with the exception of one resident who received nutrition via tube feeding.
Failure to Obtain Required Protective Placement Documentation for Resident with Guardian
Penalty
Summary
The facility failed to ensure that a resident with a legal Guardian had the required court-ordered protective placement documentation, as mandated by State Statute Chapter 55.03(4) for residents whose nursing home stay exceeds 90 days. The resident, who had diagnoses including traumatic brain injury, restlessness and agitation, anxiety, and mood disorder, was admitted with Michigan Guardian paperwork for healthcare decisions. Despite the resident's intact cognition as indicated by a BIMS score of 14 out of 15, the medical record did not contain evidence of the necessary protective placement documentation. Staff interviews and record reviews revealed that the Social Services Director notified the Aging and Disability Resource Center Staff (ADRCS) about the need for protective placement and provided communication records. ADRCS requested specific guardianship documents from the facility, but these were not provided. Further, ADRCS identified that the protective placement paperwork should be filed in the county where the resident previously resided, and attempts to obtain the necessary documents from that county were made. However, the required protective placement documentation was not present in the resident's record at the time of the survey.
Failure to Notify Ombudsman of Resident Hospital and ED Transfers
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of hospital and emergency department (ED) transfers for two residents, as required by facility policy. One resident experienced a change in condition and was transferred to the hospital, but this transfer was not included in the monthly report sent to the Ombudsman. The omission was confirmed by the staff member responsible for submitting these reports, who acknowledged that the transfer should have been reported. Another resident was transferred to the ED on two separate occasions due to changes in condition and returned to the facility the same days. These ED transfers were also not included in the monthly report to the Ombudsman. The staff member responsible for notifications indicated a lack of awareness that ED transfers required notification to the Ombudsman, resulting in these events not being reported as mandated by facility policy.
Failure to Update PASRR Screens After Changes in Mental Health Diagnoses and Medications
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level I Screens were updated and, when indicated, Level II Screens were initiated for residents who experienced changes in mental health diagnoses and psychotropic medication orders. For one resident, who had diagnoses including dementia, anxiety, depression, and psychotic disorder, the medical record showed a severely impaired cognitive status and new or changed orders for antianxiety, antipsychotic, and antidepressant medications. Despite these changes, the resident's PASRR Level I Screen was not updated, nor was a Level II Screen completed, as required when new mental disorders or psychotropic medications are identified. Similarly, another resident with multiple neurocognitive and psychiatric diagnoses, including major depressive disorder and anxiety disorder, received new or changed orders for several psychotropic medications, such as antianxiety, anticonvulsant, antidepressant, and antipsychotic drugs. The resident's PASRR Level I and Level II Screens were not updated to reflect these changes. Staff interviews confirmed that the responsible personnel were aware of the medication and diagnosis changes but did not update or resubmit the required PASRR screenings.
Failure to Provide Adequate Supervision and Assistance Devices for Resident with Fall History
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices for a resident with a history of multiple falls. The resident, who had diagnoses including dementia, psychotic disturbance, anxiety, frontal lobe and executive function deficit, Parkinson's disease, and spondylosis, was assessed as not cognitively impaired and had a corporate guardianship for healthcare decisions. The resident's care plan required limited assistance with bed mobility and transfers, supervision with toilet hygiene, and the use of a wheeled walker and gait belt, with the bed to be kept in a low position. Despite these interventions, the resident experienced seven unwitnessed falls over six months, and observations revealed that the resident was allowed to ambulate and transfer independently in their room, with the bed not maintained in a low position as specified in the care plan. Interviews with staff indicated inconsistency in following the care plan, with some staff stating the resident was independent with transfers and toileting, while others noted a preference to assist due to hygiene concerns. The resident reported being independent with these activities, and staff acknowledged that the resident did not always call for assistance as required. The Director of Nursing confirmed that staff are expected to follow residents' care plans, but the observed practices did not align with the documented interventions, contributing to the repeated falls.
Failure to Follow Infection Control Protocols for Residents on Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program for two of seven sampled residents. For one resident on droplet precautions due to upper respiratory symptoms and a positive rhinovirus test, a maintenance/transport employee entered the resident's room and performed tasks without wearing a mask, gloves, or eye protection, despite clear signage indicating the required personal protective equipment (PPE) and the resident's need for droplet precautions. The staff member's lack of appropriate PPE use was confirmed by both direct observation and staff interviews, and the facility's policy required mask, gloves, and eye protection for droplet precautions. In a separate incident, another resident on enhanced barrier precautions (EBP) for multidrug-resistant organism risk received intravenous medication from the Assistant Director of Nursing, who wore gloves but failed to don a gown as required for high-contact resident care activities under the facility's EBP policy. The EBP signage was posted outside the resident's room, and the staff member acknowledged the omission during an interview. The Director of Nursing also confirmed that administering IV medication is considered high-contact care and requires the use of a gown according to facility policy.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate care and services to prevent pressure injuries from developing and promote healing for a resident. The resident, who had multiple diagnoses including peripheral vascular disease and diabetes, developed a wound on the left foot that was initially misclassified as an arterial wound by a non-wound care certified staff member. This misclassification led to a delay in implementing necessary pressure-relieving interventions, and the wound was not formally assessed until two weeks later. The resident was hospitalized for pneumonia and a UTI, during which the wound was reclassified as an unstageable deep tissue injury. Despite this reclassification, pressure-relieving interventions were not added to the resident's care plan until several days later. Furthermore, the facility staff failed to transcribe a new treatment order correctly, resulting in the wound care not being completed as ordered by the physician. Observations also revealed that the resident was not consistently wearing heel boots as required. These failures in assessment, monitoring, and implementation of appropriate interventions led to the wound progressing to a stage 4 pressure injury, creating a finding of immediate jeopardy. The facility's lack of timely and accurate wound care management contributed to the serious harm experienced by the resident.
Removal Plan
- Educate staff on the Pressure Injury Prevention and Wound Care Management policy, specifically related to physician orders, documentation, treatment completion, implementation of care plan interventions, and how to access the Kardex.
- Conduct a skin sweep of all residents to ensure there are no new areas of skin alteration.
- Conduct a chart audit of all residents with pressure injuries to ensure accuracy of physician orders, treatments are being completed, and care plan interventions are appropriate and effective.
- Implement a system where a second licensed staff is needed to confirm physician orders for accuracy.
- Implement skin and wound audits.
Failure to Notify Physician of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's physician when the resident was transferred to the hospital. The resident, who had a Power of Attorney for Healthcare (POAHC) and was receiving hospice services, was sent to the emergency room by their POAHC due to abnormal behavior and head pain. Despite the facility's policy requiring prompt notification of the attending physician for changes in a resident's condition, the staff only informed the hospice staff and did not notify the resident's physician. The resident, who had moderately impaired cognition and multiple serious diagnoses including malignant neoplasms, was admitted to the facility and later transferred to the hospital without the physician being informed. The Nursing Home Administrator confirmed that the physician should have been notified in addition to the hospice staff, as per the facility's policy. This oversight was identified during a surveyor's review of the resident's medical record and interviews with facility staff.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to ensure a thorough investigation of an allegation of abuse involving two residents, R1 and R2, who had altercations on two separate occasions. The facility's policy mandates timely and thorough investigations of abuse allegations, including documentation of resident behaviors during incidents and investigations. However, the report indicates that the altercations between R1 and R2 on 10/11/24 and 10/13/24 were not thoroughly investigated as required by the facility's policy. R1 and R2 both had severely impaired cognition, with R1 having a BIMS score of 5 and R2 a score of 3, indicating severe cognitive impairment. Despite the facility's initial response to the incidents, including separating the residents and notifying relevant parties, there was a lack of documentation for the 15-minute checks that were supposed to be conducted for R2 following the incidents. This lack of documentation was confirmed by the Nursing Home Administrator, who was unable to provide evidence of the checks, highlighting a deficiency in the facility's adherence to its own abuse prevention and investigation protocols.
Inconsistent Oral Care Documentation for Residents
Penalty
Summary
The facility failed to ensure consistent oral care for three residents, as identified during a survey. The facility's policy requires daily documentation of oral care, including instances of refusal or unavailability. However, for one resident, oral care was not documented as completed for two days, with additional days marked as refused or completed. This resident had moderately impaired cognition and required partial assistance for oral care. Another resident, with moderately impaired cognition and a history of stroke, did not have oral care documented on one day, with the reason for the lack of documentation being unclear. The Director of Nursing (DON) confirmed that if care is not documented, it is considered not done. A third resident, with severely impaired cognition and multiple health issues, did not have oral care documented on two separate days. The documentation for these days was marked as not applicable, and the DON was unable to explain why. The facility's failure to document oral care consistently for these residents indicates a deficiency in adhering to their own policies and procedures for activities of daily living, specifically oral hygiene.
Deficiencies in Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, R9 and R3, as observed by surveyors. For R9, the catheter tubing and uncovered drainage bag were found on the floor, which is against the CDC guidelines that state urinary drainage bags should not rest on the floor. R9 was cognitively intact, with a BIMS score of 15 out of 15, and had a history of multiple sclerosis. The facility's policy did not address the proper positioning of catheter tubing or drainage bags, and the Nursing Home Administrator acknowledged the need to review the policy. For R3, who was admitted with a Foley catheter and had moderately impaired cognition, there was no physician order or documentation for catheter care and output upon admission. R3's care plan did not address the catheter until nearly two weeks after admission, and the Director of Nursing confirmed that catheter care orders and a care plan should have been initiated upon admission. The Nursing Home Administrator noted that a mock survey had identified similar issues, but staff education had not yet been completed.
Deficiency in Call Light Functionality
Penalty
Summary
The facility failed to provide a working call light for a resident, identified as R9, which was observed during a survey. R9, who was admitted with diagnoses including multiple sclerosis, dysphagia, muscle wasting, and a pressure ulcer, had a BIMS score indicating no cognitive impairment. On the day of the survey, R9 attempted to use the call light to request repositioning, but the call light did not activate. The surveyor confirmed the malfunction after R9's second attempt and alerted a CNA, who verified the issue and stated they would contact maintenance for repair. The Nursing Home Administrator acknowledged that call lights should be operational at all times.
Deficiency in Wheelchair Cleaning and Documentation
Penalty
Summary
The facility failed to ensure a clean, comfortable, or home-like environment for a resident, identified as R4, whose wheelchair was found to be visibly dirty. The surveyor observed dried debris on both wheels and a greasy layer of dirt on a bar at the bottom of the wheelchair. Despite attempts to clean it with a glove, some dirt and debris remained. R4, who had intact cognition as indicated by a BIMS score of 13 out of 15, was unaware if the wheelchair had been cleaned and expressed a desire for it to be cleaned. The Nursing Home Administrator (NHA) stated that night shift CNAs were responsible for cleaning wheelchairs on bath days, but there was no documentation to confirm when or if this task was completed. The NHA acknowledged that staff do not document wheelchair cleaning or resident refusals of cleaning. A CNA confirmed that night shift staff were supposed to clean wheelchairs but was unsure if this was documented. The CNA also noted that other wheelchairs in the facility appeared to need cleaning.
Failure to Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide timely care and treatment for a resident who experienced a fall, resulting in a deficiency. The resident, who had a history of anemia and diabetes mellitus, was found face down on the floor with a contusion on the forehead and complained of shoulder pain. Despite the fall and the resident's altered mental status, the facility staff did not promptly notify the resident's primary care physician or send the resident to the emergency room for evaluation. The facility's Change in Condition policy required immediate notification of the physician and responsible parties in such situations, but this was not adhered to. The incident occurred when two CNAs found the resident on the floor early in the morning. The CNAs reported the fall to a nurse, who assisted in transferring the resident back to bed and initiated neurological checks. However, the nurse only documented one set of vital signs and did not perform a complete neurological assessment as required by the facility's policy. The nurse contacted an on-call physician, who was a nephrologist from a different medical group, instead of the resident's primary care physician. This miscommunication led to a delay in sending the resident to the emergency room. The resident's condition was not adequately monitored, and the facility staff failed to follow the proper protocol for notifying the correct medical personnel. The resident was eventually sent to the emergency room later in the morning, but the delay in care and treatment was significant. The facility's failure to adhere to its policies and ensure timely medical intervention contributed to the deficiency identified by the surveyors.
Failure to Provide Adequate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who expressed suicidal ideation and had recently returned from the hospital with a recommendation for 1:1 supervision. The resident, who had severe cognitive impairment and a history of mental health issues, was left unsupervised in a dining room, allowing them to crawl out of an open second-story window and walk along a narrow ledge with the intent to jump. This incident occurred despite the emergency department's instructions for continuous 1:1 supervision upon the resident's return to the facility. The resident's medical history included Alzheimer's disease, vascular dementia, schizoaffective disorder, and schizophrenia, among other conditions. Prior to the incident, the resident had shown signs of mental decline, including hallucinations and suicidal ideation, and had been placed on direct 1:1 observation after attempting self-harm. However, the facility did not ensure that the necessary supervision was in place, as evidenced by the lack of documentation and staff awareness of the 1:1 supervision requirement. Interviews with staff revealed that there was a communication breakdown regarding the resident's supervision needs. The CNA and LPN involved in the incident were not informed of the 1:1 supervision requirement, and the facility's staff schedules did not reflect any assignments for such supervision until after the incident occurred. This lack of supervision and communication created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy.
Removal Plan
- Maintained 1:1 supervision for R1.
- Educated staff on the requirements of 1:1 supervision, checking the schedule to determine who is assigned to 1:1 supervision, and referencing residents' care plans to see which residents require 1:1 supervision.
- Conducted 1:1 shift audits to ensure adequate and safe supervision was provided.
- Conducted staff interviews to ensure 1:1 supervision competency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of medications for ten residents across two medication carts. Observations revealed that insulin vials, which should be refrigerated, were left unrefrigerated, and several medications were found open, undated, and expired. Additionally, the medication carts were not locked when unattended, posing a risk of unauthorized access. The facility's policy mandates that expired medications be removed and that compartments containing medications be locked when not in use. The refrigerator in the medication storage room was not maintained at the required temperature of 41 degrees Fahrenheit or lower, as evidenced by temperature logs showing readings above the acceptable range. The logs also had missing entries, and there was no documentation of maintenance being notified about the out-of-range temperatures. This refrigerator contained unopened insulin vials, which require specific temperature conditions to maintain their integrity. Treatment carts were also found to contain expired and unlabeled treatments and were left unlocked in areas accessible to residents and visitors. The Director of Nursing confirmed that nebulizers should be kept in foil packaging and that insulin should be dated and stored properly. The facility did not track whether maintenance was informed of temperature issues, nor did they ensure that the refrigerators were checked by maintenance when temperatures were out of range.
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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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