Elroy Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Elroy, Wisconsin.
- Location
- 307 Royall Ave, Elroy, Wisconsin 53929
- CMS Provider Number
- 525452
- Inspections on file
- 25
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Elroy Health Services during CMS and state inspections, most recent first.
A resident with dementia and a history of fractures fell and complained of pain to the right wrist and hip. Although a PA ordered STAT x-rays, the imaging was not completed as ordered, and the provider was not notified of the delay or the resident's worsening pain. The resident exhibited significant pain and changes in condition overnight, but was only sent to the ER the next morning, where multiple fractures were diagnosed. Staff interviews confirmed that required notifications and timely actions were not taken.
A resident with severe cognitive impairment and a history of falls was not provided with an environment free from accident hazards due to the facility's failure to incorporate family-provided information about her routines and preferences into her care plan or Kardex. Staff were unaware of key details such as her preference to sleep in a recliner in street clothes, and relied on education as a fall prevention measure despite her inability to follow instructions. The resident's behavior of disabling her own alarm was not addressed in her care plan, and the alarm was not functioning at the time of an unwitnessed fall that resulted in a hip fracture.
A resident with Alzheimer's disease was prescribed Olanzapine, an antipsychotic, without an appropriate clinical indication or documentation that non-pharmacological interventions were attempted or contraindicated. The medication was ordered for behaviors common in Alzheimer's, such as wandering and lack of safety awareness, which do not alone justify antipsychotic use according to facility policy.
The facility failed to provide adequate care to prevent and treat pressure injuries for two residents. One resident developed two stage 3 pressure injuries due to improper repositioning and treatment application, while another resident's pressure injury deteriorated due to lack of proper assessment and care. Observations revealed multiple layers between residents and air mattresses, and staff failed to document repositioning and incontinence care consistently.
The facility failed to provide adequate nursing staff, leading to long wait times for resident assistance and unmet care needs. Staffing levels were based on census rather than resident acuity, resulting in insufficient care, particularly on weekends. Residents reported delays in call light responses and meal service, while staff confirmed they were unable to complete all care tasks due to low staffing.
The facility did not maintain a sanitary environment for food service, affecting all residents. A dietary aide was observed without a beard restraint, garbage cans near the food prep area lacked lids, and a spill was found in the walk-in fridge. The Dietary Manager and Nursing Home Administrator acknowledged these issues.
The facility failed to maintain an effective infection prevention and control program during a COVID outbreak, with staff unaware of the outbreak and not adhering to mask-wearing protocols. The outbreak was prematurely declared resolved, and staff surveillance was incomplete, leading to staff returning to work too early after illness. These deficiencies potentially affected all 68 residents.
The facility failed to maintain a safe and comfortable environment, as the dining room was observed to be significantly cold, with temperatures recorded at 56.8 degrees Fahrenheit. Residents, including those with cognitive impairments, were seen wearing jackets or blankets to stay warm. Despite being aware of the issue from a Resident Council meeting, the facility had not implemented effective measures to resolve the problem, and staff confirmed the cold conditions.
The facility failed to provide an ongoing program to support resident choice of activities, as observed in four residents on D Hallway who were not offered or did not participate in meaningful activities. Despite documented preferences for activities, many days lacked any participation documentation. Staff interviews revealed issues such as understaffing and a lack of activities tailored for residents with dementia, contributing to the deficiency.
A resident was observed wearing only a hospital gown in the dining room, expressing discomfort and a lack of clothing options. Despite being cognitively intact, the resident had no access to his clothes, which were in his assisted living apartment, and had not been offered alternative clothing by the facility staff. The social worker acknowledged the issue and arranged for the resident's clothes to be brought, but only after the surveyor's inquiry were alternative clothes offered.
Two residents in a LTC facility expressed dissatisfaction with receiving scrambled eggs daily, despite communicating their preferences to the kitchen. Both residents, who are cognitively intact, had meal tickets that did not reflect their dislike for scrambled eggs. The facility's process for updating dietary preferences was not effectively implemented, leading to a deficiency in promoting resident self-determination.
A facility failed to report a resident-to-resident verbal abuse incident within the required timeframe. A resident with a history of verbal aggression caused another resident to cry, but the incident was not reported to the state agency. Despite staff acknowledging the behavior as abuse, the DON and NHA did not consider it reportable, leading to a violation of the facility's policy.
A facility failed to investigate an incident of resident-to-resident verbal abuse when a resident changed the TV channel in a shared space, leading to a verbal altercation with another resident who became visibly upset. Despite staff witnessing the incident and considering it verbal abuse, the facility did not conduct a formal investigation or follow its policy on abuse allegations.
A facility failed to develop a comprehensive care plan for a resident with schizoaffective disorder and behavioral symptoms. Despite the resident's cognitive intactness and documented behaviors, the care plan lacked objectives and interventions for psychosocial well-being. Staff interviews revealed attempts to manage behaviors verbally, but no specific interventions were documented. The DON acknowledged the absence of a care plan addressing the resident's behaviors.
A resident with dementia exhibited aggressive behaviors, but the facility failed to develop an individualized care plan addressing these behaviors. Staff reported that the resident often refused care and medications, and interventions were not documented. The Director of Nursing acknowledged the need for a care plan, but it was not implemented, leading to inadequate care for the resident.
A resident's COVID-19 status was inappropriately disclosed by a CNA in front of others, violating privacy rights. Additionally, the Social Services Director publicly reprimanded the resident for not following smoking protocols, causing discomfort and fear. These actions breached the facility's policies on resident rights and privacy.
A resident with a cervical disc disorder requiring assistance with ADLs did not receive showering or bathing services for 21 days during a COVID quarantine. Despite being scheduled for weekly showers, the facility failed to provide these services due to staffing shortages. The resident reported not receiving a shower or bath for over two weeks, and the facility's documentation confirmed the lack of services. The issue was not addressed until a complaint investigation began.
A resident with a history of falls and poor safety awareness experienced an unwitnessed fall. The facility failed to conduct a timely post-fall assessment as per their guidelines. The nurse on duty did not assess the resident until the next day, and the physician was informed over 24 hours later. This delay in assessment and reporting led to a deficiency in the quality of care provided.
A resident with multiple pressure ulcers did not receive wound care according to physician orders. The RN applied medi honey instead of the prescribed treatment and used paper towels for cleansing, which was inappropriate. The facility was out of the required calcium alginate, and the RN was terminated after this incident.
The facility failed to ensure a safe and homelike environment, as several residents reported non-functional sinks and a lack of hot water for weeks. Observations confirmed musty odors and inadequate water temperatures. Staff acknowledged the ongoing issues, and maintenance efforts had not resolved the problems.
The facility failed to provide showers to residents due to a lack of hot water, affecting their personal hygiene. Residents reported missing showers, and documentation showed they were not offered showers on specific dates. Staff confirmed the issue, with attempts to use cold water or transport hot water from other areas. The Director of Maintenance struggled to resolve the hot water system issues, impacting residents' ability to have hot showers.
The facility failed to maintain safe water temperatures, resulting in excessively hot water in some resident bathrooms. Residents reported concerns, and a surveyor confirmed unsafe temperatures. The Director of Maintenance acknowledged ongoing issues with the water system, and the Nursing Home Administrator was aware but reported no injuries.
A resident with a cognitive communication deficit reported verbal abuse by CNAs, involving yelling and swearing, through the grievance process. Despite facility policy requiring immediate reporting of such allegations, the Nursing Home Administrator did not report the incident to the state agency within the required timeframe.
A resident with a cognitive communication deficit reported verbal abuse by CNAs, including yelling and swearing. Despite the resident's intact cognition, the facility did not conduct a thorough investigation, failing to interview involved parties or remove staff from working with the resident.
A resident with moderate cognitive impairment was found holding a medication cup with pills without staff supervision. The facility did not complete a self-administration assessment or obtain a physician order for the resident to self-administer medications. The RN admitted to leaving the medications with the resident, contrary to facility policy requiring an assessment and prescriber's order.
Failure to Complete STAT Imaging and Notify Provider After Resident Fall
Penalty
Summary
A resident with a history of osteoarthritis, previous traumatic fracture, and dementia experienced a fall resulting in complaints of pain to the right wrist and right hip. A physician assistant present at the time assessed the resident and ordered STAT x-rays of the right wrist, pelvis, and hip. Despite these orders, the x-rays were not completed as directed. The facility's process involved contacting a mobile imaging service, but the imaging was not performed the same day, and there was no documentation of follow-up with the provider regarding the delay. Throughout the evening and night following the fall, the resident exhibited signs of significant pain, including shaking and a refusal to ambulate or get out of the wheelchair, which was a change from her baseline. These symptoms were reported to nursing staff, but the provider was not notified of the resident's ongoing pain or the failure to complete the STAT imaging. The facility's policy required immediate notification of the provider and the resident's representative in the event of a significant change in condition or if treatment could not be provided as ordered, but this did not occur. The next morning, the resident was found to be in severe pain and was subsequently sent to the emergency room, where she was diagnosed with fractures to the right hip, pelvis, and wrist. Interviews with facility staff confirmed that the provider was not informed of the delay in imaging or the resident's change in condition until after the resident was sent to the hospital. The failure to complete the STAT x-rays as ordered and to communicate this to the provider resulted in a delay in treatment for the resident.
Failure to Prevent Accident Hazards and Integrate Person-Centered Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with Alzheimer's disease and assessed as severely cognitively impaired with a BIMS score of 3 out of 15, was admitted with multiple risk factors including confusion, impulsivity, and a recent history of recurrent falls. Despite the family's provision of detailed information regarding the resident's routines and preferences, such as sleeping in a recliner in street clothes and keeping a specific TV channel on, this information was not incorporated into the resident's baseline or comprehensive care plan, nor was it communicated to frontline staff through the Kardex or other official documentation. The facility's own fall prevention policy required individualized interventions based on assessment and family input, but the care plans lacked person-centered interventions and did not address the resident's behavior of deactivating her own alarm system. Staff relied on educating the resident as a fall prevention measure, despite documentation that the resident was only oriented to self and unable to reliably follow instructions due to severe cognitive impairment. The alarm system intended to alert staff to self-transfers was either not functioning or was turned off at the time of the resident's unwitnessed fall, and there was no documentation of interventions or monitoring related to the resident's known behavior of disabling the alarm. As a result, the resident experienced multiple falls, including an unwitnessed fall that resulted in a left hip fracture requiring surgical intervention. Interviews with staff revealed that key information about the resident's preferences and routines was not available in the care plan or Kardex, and staff were unaware of these preferences, leading to deviations from the resident's established routine. The facility's management acknowledged that person-centered information provided by the family was not integrated into the care planning process, and the care plan did not include goals or interventions to address the resident's behavior of disabling her alarm.
Unnecessary Use of Antipsychotic Medication Without Proper Indication
Penalty
Summary
The facility did not ensure that a resident was free from unnecessary psychotropic medications, as required by policy and regulation. One resident with a diagnosis of Alzheimer's disease with late onset was prescribed Olanzapine, an antipsychotic medication, without an appropriate clinical indication documented in the medical record. The facility's policy states that psychotropic medications should only be used when non-pharmacological interventions are clinically contraindicated and when there is a documented, adequate indication for use. In this case, the physician order listed Alzheimer's disease with late onset as the reason for the antipsychotic, which is not an appropriate indication for such medication. During interviews, the prescribing physician assistant stated that the medication was given due to the resident's severe psychosis, impulsivity, and lack of safety awareness, describing behaviors such as wandering and attempting to stand without assistance. However, these behaviors are common in individuals with Alzheimer's disease and do not necessarily justify the use of antipsychotic medication. The facility failed to document persistent and harmful behaviors or evidence that non-pharmacological interventions were attempted or clinically contraindicated prior to initiating the antipsychotic. As a result, the resident received an unnecessary psychotropic medication without proper justification.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards to prevent and treat pressure injuries. Two residents, identified as R35 and R44, were affected by these deficiencies. R35, who was at risk for pressure injury development, developed two stage 3 facility-acquired pressure injuries that deteriorated. Observations revealed multiple layers between R35 and the air mattress, and the facility did not provide education or discuss risks versus benefits when R35 declined repositioning. Additionally, staff failed to consistently document repositioning or incontinence care, which contributed to R35's pressure injuries. The prescribed treatment was not applied correctly, as the periwound was not protected during application. R35's care plan was not updated to reflect current wounds and locations, and the repositioning intervention was added 22 days after the development of the pressure injury. Despite the deterioration of R35's moisture-associated skin damage to a stage 3 pressure injury, the facility continued to document this injury on the non-pressure wound tracker. The facility also failed to document repositioning opportunities consistently, with 86 missed documentation instances. During wound care observations, it was noted that the Dakin solution was not properly applied, potentially causing harm to healthy skin. R44 was admitted with a pressure injury that was initially documented as stage 2 but had 50% slough, indicating it was at least stage 3. The facility failed to complete weekly pressure injury assessments per standards of practice, and R44's pressure injury deteriorated, evidenced by undermining and tunneling. Observations also revealed multiple layers between R44 and the air mattress. These failures led to a finding of immediate jeopardy, which was later removed, but the deficient practice continued at a scope/severity of G (actual harm/isolated).
Removal Plan
- Both residents remain at the center and care plan regarding pressure injury reviewed and updated.
- In-house residents with pressure injuries have the potential to be affected. Skin sweep completed.
- Director of nursing or designee implemented re-education with nursing staff (CNAs and licensed nurses) on Pressure Injury and Non-Pressure Injury policy and Use of Support Surface policy.
- Education included the need to ensure care plan is followed including managing moisture and incontinence including not using multiple layers with air mattresses.
- If cares/treatments are refused to notify licensed nurse/DON/designee and education provided on risks and benefits to resident or responsible party, notify MD and update care plan.
- Obtaining Periwound treatment in order from MDs.
- Wound assessments including measurements and ensuring surface area adds up to 100% of assess.
- Identified education will occur prior to start of next scheduled shift.
- Facility reviewed their Pressure Injury and Non-Pressure Injury and Use of Support Surface policies. No changes were required to policies.
- DON/designee also verified that residents with pressure injuries have accurate assessment of pressure injuries, including physician orders for treatment and dressing changes that are completed per MD order.
- Interdisciplinary review completed of care plans for residents with pressure injuries and a visual audit was completed by Director of Nursing or designee to ensure care planned interventions for pressure injury healing and prevention are in place.
- DON/designee to complete random observation (audit) of dressing changes per MD order with periwound treatment, if warranted, and cares/treatment to ensure dressing changes completed per MD order, interventions to promote healing including no multiple layers on air mattresses, and ensure proper documentation of refusal of skin care and treatment.
- Audits will also include Pressure injury weekly documentation to ensure accurate and complete, and CNA task documentation on if cares accepted and documented per care plan.
- Audits will be completed daily. These audits will then continue on varying shifts three times per week for additional weeks then 2 times per week for additional weeks.
- Results of audits will be presented to facility QAPI committee for review and any recommendations.
- Ad hoc QAPI meeting held to review this plan.
Inadequate Staffing Leads to Compromised Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews conducted by surveyors. The staffing levels were based on census and hours per patient day (HPPD) without considering the acuity of the resident population. This resulted in inadequate care, with residents experiencing long wait times for assistance, particularly during weekends when staffing was notably low. The facility's HPPD often fell below the ideal 3.0, with only one day meeting or exceeding this standard. Residents expressed concerns about delayed responses to call lights and untimely meal service, which were corroborated by staff interviews. Several residents, including those with significant care needs such as arthritis, muscle weakness, and cognitive impairments, reported waiting extended periods for assistance with toileting and other activities of daily living. Staff members confirmed that they were unable to complete all necessary care tasks due to insufficient staffing, leading to unmet needs in areas such as oral care and repositioning. The deficiency was further highlighted by observations of inadequate supervision during meal times, where residents requiring assistance were left struggling to eat. Staff interviews revealed that the lack of sufficient personnel often left one CNA responsible for an entire hallway, exacerbating the issue. The facility's failure to adjust staffing levels to accommodate the specific needs of its residents resulted in compromised care and dissatisfaction among both residents and staff.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 68 residents. During a kitchen tour, a surveyor observed a dietary aide not wearing a beard restraint, which is against the facility's policy on employee sanitary practices. Additionally, garbage cans without lids were found near the food preparation area, and a yellow substance, likely eggs, was spilled in the walk-in refrigerator. The Dietary Manager acknowledged these issues, and the Nursing Home Administrator confirmed the expectation for staff to adhere to hygiene and safety protocols.
Inadequate Infection Control and Staff Surveillance During COVID Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which was evident through multiple observations and interviews. The outbreak that began in October 2024 was prematurely declared resolved, and staff were not aware of the ongoing outbreak, leading to improper source control measures. The facility's policy required the outbreak to be considered resolved only after two incubation periods without new cases, which was not adhered to as the outbreak was ended on day 15. This oversight potentially affected all 68 residents in the facility. During the survey, several staff members, including a Dietary Aide, a CNA, and a Pest Control Contractor, were observed not wearing masks or wearing them incorrectly despite the facility being in a COVID outbreak. Interviews revealed that staff were either unaware of the outbreak or misunderstood the requirements for mask-wearing. The Director of Nursing confirmed the facility had been in outbreak status since early February 2025, yet staff compliance with mask-wearing was inconsistent. The facility's staff surveillance was incomplete, with several instances of staff returning to work too early after reporting symptoms of illness. The staff line list lacked documentation of symptom resolution dates, making it difficult to determine if staff returned to work prematurely. The Infection Preventionist acknowledged these gaps, noting that staff with gastrointestinal symptoms should remain out of the facility for 48 hours after symptoms resolve, which was not consistently followed. Additionally, COVID testing was not documented for staff with symptoms, further indicating lapses in the infection control program.
Cold Dining Room Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the cold temperatures in the dining room. Multiple residents, including those with varying levels of cognitive impairment, were observed wearing jackets or wrapped in blankets to stay warm while dining. The surveyor noted that the dining room temperature was significantly below the facility's policy range of 71 to 81 degrees Fahrenheit, with a recorded temperature of 56.8 degrees Fahrenheit. The issue was acknowledged in a Resident Council meeting, indicating that the facility was aware of the residents' concerns about the cold dining room. Despite this awareness, the problem persisted, as observed by the surveyor over several days. The Nursing Home Administrator (NHA) admitted that the facility needed new boilers and additional insulation to maintain appropriate temperatures, but these measures had not yet been implemented. The surveyor's interviews with staff, including the NHA and a Physical Therapy Assistant, confirmed that the cold temperature was a known issue. The NHA stated that the facility respected residents' choices to eat in the dining room, even when temperatures were low. Maintenance staff did not monitor the ambient temperature, and the NHA acknowledged that the temperature was not acceptable, yet corrective actions were not effectively taken to address the deficiency in a timely manner.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident. This deficiency was observed in four residents residing on D Hallway, who were not offered or did not participate in meaningful activities. The facility's policy on activities, dated 7/11/22, outlines the importance of designing activities to enhance residents' well-being, cognition, and emotional health, among other aspects. However, the surveyor's observations and record reviews revealed that the facility did not adhere to this policy. One resident, diagnosed with Alzheimer's disease and other conditions, expressed a desire to engage in activities meaningful to her, such as attending religious services, socializing, and participating in various hobbies. Despite these preferences being documented in her care plan, there were numerous days with no activity participation documented, and the resident was observed not participating in any activities during the survey period. Similar patterns were observed with other residents, who also had documented preferences for activities but were not engaged in them, with many days lacking any activity participation documentation. Interviews with staff, including CNAs and the Life Enrichment Specialist, highlighted issues such as understaffing and a lack of activities tailored for residents with dementia. Staff acknowledged the need for more activities and assistance for residents who are not independent in structuring their own activities. The Nursing Home Administrator was aware of the concerns regarding the lack of activities for residents on D Hallway, but the deficiency persisted, indicating a failure to implement an effective activity program that meets the needs and preferences of the residents.
Resident Denied Dignified Clothing Options
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for a resident who was observed wearing only a hospital gown and gripper socks in the dining room on multiple occasions. The resident expressed discomfort and a preference not to wear a hospital gown, stating that he felt exposed and cold. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview of Mental Status, the resident had no access to his clothes, which were in his assisted living apartment, and had not been offered alternative clothing options by the facility staff. The resident's family lived out of state, and he had no one to bring his clothes from his apartment. The social worker acknowledged the situation and mentioned that arrangements were being made to have the resident's clothes brought to him. However, it was only after the surveyor's inquiry that the social worker considered offering clothes from the facility's lost and found. The resident confirmed that this was the first time he had been offered alternative clothing, highlighting a lapse in the facility's adherence to its policy of respecting and promoting resident rights.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting the food preferences of two residents, R44 and R15. Both residents expressed dissatisfaction with receiving scrambled eggs almost every day for breakfast, despite having communicated their preferences to the kitchen staff. R44, who is cognitively intact with a BIMS score of 15, reported that her meal ticket did not reflect her preference against scrambled eggs. Similarly, R15, with a BIMS score of 13, was observed expressing her dislike for scrambled eggs, which was not addressed by the staff, and her meal ticket also lacked any indication of her preference. The surveyor's observations and interviews revealed that the facility's process for updating meal tickets with resident preferences was not effectively implemented. The Business Office Manager (BOM) acknowledged that substitutions are accommodated but did not offer one to R15 when she expressed her dislike for scrambled eggs. The facility's policy on resident rights emphasizes the importance of honoring resident choices, yet the dietary preferences of R44 and R15 were not updated or respected, leading to a deficiency in promoting resident self-determination.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident verbal abuse within the required timeframe. On February 10, 2025, a resident with a history of verbal aggression, identified as R50, was verbally aggressive towards another resident, R53, causing him to cry. Despite being aware of the incident, key staff members, including the Unit Clerk, Nursing Home Administrator (NHA), Director of Nursing (DON), and a Registered Nurse (RN), did not report the incident to the state agency as required by the facility's policy. The facility's policy mandates that all incidents involving abuse must be reported immediately, but no later than two hours after the incident if it involves abuse. However, the incident was not reported, and the facility did not recognize the resident's verbally aggressive behavior as abuse. Interviews with staff members revealed that R50's behavior was known to be problematic, with several incidents occurring in the bird room where R50 would scream at other residents, including R53, to assert control over the space. Despite the RN and Unit Clerk acknowledging the behavior as verbal abuse, the DON and NHA did not consider it reportable. The DON believed R50's yelling was not directed at R53, while the NHA thought the outbursts were directed at staff rather than residents. This misinterpretation led to a failure to report the incident, violating the facility's policy and state regulations, as the facility did not document a rationale for not reporting the incident.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted in response to an allegation of resident-to-resident verbal abuse involving two residents, R50 and R53. The incident occurred when R50 changed the TV channel in a shared space, leading to a verbal altercation with R53, who was watching TV. R50's actions and subsequent yelling caused R53 to become visibly upset and leave the room in tears. Despite the incident being reported to the Nursing Home Administrator (NHA) and the Director of Nursing (DON), no formal investigation was initiated. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of any allegations, including interviewing all involved parties and documenting the findings. However, in this case, the facility did not follow these procedures. The DON and NHA reviewed the documentation but did not consider the incident as verbal abuse, and no formal investigation was conducted. Staff members, including RN I, who witnessed the incident, considered it verbal abuse, but their concerns were not adequately addressed. The lack of a thorough investigation is evident as no statements were taken from the involved residents or staff witnesses, and no follow-up was conducted with other residents who might have been affected. The facility's failure to adhere to its policy resulted in an incomplete response to the alleged abuse, leaving the situation unresolved and potentially affecting the well-being of the residents involved.
Failure to Implement Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident diagnosed with schizoaffective disorder, severe obsessive-compulsive disorder, and anxiety. Despite the resident's cognitive intactness and documented behavioral symptoms such as yelling, screaming, and abusive language, the care plan did not address psychosocial well-being or behavioral symptoms. The facility's policy mandates that care plans include measurable objectives and timeframes to meet residents' needs, but this was not adhered to for the resident in question. Interviews with staff, including a Med Tech, CNA, RN, and the Director of Nursing, revealed a lack of specific interventions for managing the resident's behaviors. Staff members attempted to manage the resident's behaviors through verbal de-escalation and redirection, but there were no documented interventions or behavior monitoring orders in the care plan. The Director of Nursing acknowledged the absence of a care plan addressing the resident's behaviors, which would make it difficult for staff to know effective de-escalation interventions.
Failure to Provide Individualized Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, identified as R50, to maintain their highest practicable physical, mental, and psychosocial well-being. R50, who has a history of verbally aggressive and socially inappropriate behavior, did not have a comprehensive care plan that included their dementia diagnosis or specific goals and interventions for their care. The facility's policy on dementia care emphasizes the need for an interdisciplinary team approach to develop and implement individualized care plans, but this was not adhered to in R50's case. Observations and interviews with facility staff revealed that R50 exhibited behaviors such as yelling, screaming, and using abusive language, which were not consistently documented or addressed with specific interventions. Staff members, including CNAs and nurses, reported that R50 often refused care, medications, and vital sign monitoring, and would become aggressive if disturbed. Despite these behaviors, there were no documented interventions on R50's care plan or CNA Kardex, and staff generally responded by giving R50 space rather than implementing structured interventions. The Director of Nursing acknowledged that R50's behaviors and dementia diagnosis should have been included in the care plan, along with appropriate interventions. The lack of a detailed care plan made it difficult for new employees to understand how to manage R50's behaviors effectively. This oversight resulted in a failure to meet the facility's policy requirements and the resident's care needs, as outlined in the State Operations Manual, Appendix PP, which highlights the importance of addressing behavioral expressions related to dementia through individualized care plans.
Breach of Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical information, specifically regarding her COVID-19 status. During an interaction outside the facility, a Certified Nursing Assistant (CNA1) disclosed the resident's COVID-19 status in front of other residents and a hospice staff member. This disclosure occurred when the resident questioned why she could not have a shower, and CNA1 responded that it was due to her COVID-19 status. The resident expressed feeling offended by this breach of privacy, and CNA1 later acknowledged that discussing the resident's health status in front of others was inappropriate. Additionally, the Social Services Director (SSD) publicly reprimanded the same resident for not following the facility's smoking protocol. This incident occurred at the front entrance of the facility, where other residents, visitors, and staff could hear the exchange. The resident reported feeling scared and uncomfortable as the SSD approached her closely and continued to reprimand her despite her protests. The Unit Clerk, who witnessed the incident, confirmed that the reprimand was inappropriate in a public setting. The facility's policies on resident rights and privacy were not adhered to in these instances. The Director of Nursing (DON) confirmed that medical information should remain confidential and was unaware of the breach by CNA1. The SSD and DON both denied raising their voices during the smoking protocol incident, although the resident and other staff members reported otherwise. These events highlight a failure to respect the resident's right to privacy and dignity, as outlined in the facility's policies.
Failure to Provide ADL Assistance During COVID Quarantine
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident during a COVID quarantine period. The resident, who was admitted with a primary diagnosis of cervical disc disorder with myelopathy, required assistance with showering and bathing due to an ADL self-care deficit. Despite being scheduled for showers on Mondays, the resident did not receive any showering or bathing services for 21 days, from October 9 to October 29, 2024, while on COVID quarantine. There was no documentation indicating that the resident refused these services. Interviews with staff revealed that the facility's policy was for residents to receive a shower at least once weekly, with bed baths provided on non-shower days. However, due to staffing shortages exacerbated by COVID, the facility struggled to maintain this schedule. The CNA responsible for showers confirmed that residents on COVID quarantine were supposed to receive bed baths, but this did not occur consistently. The Director of Nursing acknowledged the staffing challenges and confirmed that the resident's documentation showed no record of showers or bed baths during the specified period. The resident reported not receiving a shower or bath for over two weeks and not being provided with washcloths or assistance in changing clothes for at least five days. The facility's Administrator was unaware of the issue until the complaint investigation began. The facility had a past non-compliance plan regarding shower documentation, but audits to ensure compliance had not been conducted, and the education for staff on proper documentation was only initiated after the investigation started.
Failure to Provide Timely Post-Fall Assessment
Penalty
Summary
The facility failed to provide timely assessment and care for a resident (R6) after she sustained an unwitnessed fall. According to the facility's Fall Prevention and Management Guidelines, a post-fall assessment should include a physical assessment with vital signs, neuro checks, and immediate notification of any abnormal findings to the physician. However, after R6's fall, there was no immediate assessment conducted by the nurse on duty, RN3. The fall occurred at 12:30 AM, but the physician was not informed until over 24 hours later, and the assessment was not documented until the next day. The resident, who had a history of poor safety awareness and required assistance for transfers, was found on the floor by CNAs, who were instructed to move her without a nurse's assessment. Interviews with staff confirmed that RN3 was aware of the fall but did not assess the resident until the following day. The DON confirmed that the expectation was for immediate assessment and reporting of falls. The resident's care plan indicated she was at risk for falls and had a history of self-transferring unsafely. The failure to follow the facility's policy for fall management and timely assessment led to a deficiency in the quality of care provided to the resident.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as R3, by not following physician orders related to wound care. R3 was admitted with a primary diagnosis of heart failure and had multiple pressure ulcers requiring specific wound care treatment. The care plan indicated that R3 needed extensive assistance with repositioning and hygiene, and was resistive to turning and repositioning. The physician's orders specified cleansing the wound with a wound cleanser, applying skin prep, and using calcium alginate to the wound bed, which was to be covered and secured with a foam border twice daily unless soiled. On a specific date, RN1 did not complete the wound treatment according to the physician's orders. Instead, RN1 applied medi honey to the wound, which was not part of the prescribed treatment, and used paper towels to cleanse the wound, which is not an appropriate method for wound care. The facility's investigation confirmed that RN1 did not follow the physician's orders, and it was noted that the facility was out of the required calcium alginate. RN1 was terminated following this incident and another unrelated incident. The resident, R3, was severely cognitively impaired and refused to be interviewed about the incident.
Deficiency in Providing a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by the lack of functional sinks and hot water. Residents R8 and R7 reported that their bathroom sinks had been inoperative for over a week, requiring them to use sinks down the hallway for personal hygiene. The surveyor observed a musty, mildew odor in their bathrooms, with visible holes and dried drip lines where the sinks had been removed. The Director of Maintenance acknowledged that these issues were on his list to address. Additionally, residents R2, R1, R5, and R3 expressed concerns about not having hot water in their rooms for approximately three weeks. The surveyor confirmed the absence of hot water by recording water temperatures that were significantly below the expected levels. Staff members, including a CNA and an RN, corroborated these issues, noting that they had been ongoing for weeks and affected their ability to provide proper care, such as handwashing and resident showers. The Director of Maintenance indicated that the hot water system had been problematic, with some areas of the building receiving excessively hot water while others had none. Despite replacing several components of the water system, the issue persisted, and additional parts were on order. The Nursing Home Administrator acknowledged the ongoing struggle with the recirculating water system and mentioned the possibility of needing to call a Master Plumber for assistance.
Deficiency in Providing Showers Due to Lack of Hot Water
Penalty
Summary
The facility failed to provide showers to four residents due to a lack of hot water, as evidenced by interviews and record reviews. Residents reported missing showers because the facility did not have hot water available in their hallway. The facility's policy on Activities of Daily Living (ADLs) requires that residents receive necessary services to maintain personal hygiene, including bathing. However, documentation showed that residents were not offered showers on specific dates, and there was no indication that they refused them. This issue affected residents with varying cognitive abilities, including those with intact cognition and those with moderate cognitive impairment. The problem persisted for several weeks, as confirmed by staff interviews. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) both indicated that the lack of hot water led to missed showers, with staff sometimes resorting to using cold water or transporting hot water from other areas. The Director of Maintenance acknowledged ongoing struggles with the hot water system, having replaced several parts and ordered more to address the issue. The Nursing Home Administrator (NHA) confirmed the inconsistency in hot water availability, particularly in one hallway, which affected the residents' ability to have hot showers.
Unsafe Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident environments were free from potential accident hazards, specifically concerning hot water temperatures, for three residents. Residents voiced concerns about excessively hot water, and the surveyor confirmed these concerns by recording unsafe water temperatures in the residents' bathrooms. The facility's policy on safe water temperatures mandates that water should not exceed the state's allowable maximum temperature, and staff should monitor residents for signs of burns. However, the surveyor found water temperatures as high as 127.6 degrees Fahrenheit, which poses a risk of burns. The Director of Maintenance acknowledged ongoing issues with the hot water system, including inconsistent water temperatures throughout the facility. Despite replacing several parts of the water system, the problem persisted, with some areas receiving excessively hot water while others had insufficient hot water. The Nursing Home Administrator was aware of the issue but had not reported any injuries resulting from the hot water. The facility's failure to maintain safe water temperatures and adequately address the malfunctioning water system led to the deficiency.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by state law. A resident, identified as R7, reported an allegation of verbal abuse through the facility's grievance process, stating that two CNAs were behaving unprofessionally by yelling, screaming, and swearing. Despite the facility's policy requiring immediate reporting of such allegations to the state agency, the Nursing Home Administrator did not report the incident within the mandated two-hour timeframe. R7, who was admitted with a cognitive communication deficit and an intact cognition score, expressed dissatisfaction with the treatment received from CNA G, who allegedly used explicit language and made R7 feel demeaned. The Nursing Home Administrator acknowledged that such behavior could be perceived as abuse, especially by someone with cognitive deficits, but did not report the incident to the state agency, citing a lack of direct evidence that the behavior was directed at R7.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for a resident. The resident, who has a cognitive communication deficit and an unspecified injury of the head, reported an allegation of verbal abuse through the grievance process. The grievance described unprofessional behavior by two CNAs, including yelling, screaming, and swearing. Despite the resident's intact cognition, as indicated by a BIMS score of 13 out of 15, the facility did not conduct a thorough investigation into the allegations. The Nursing Home Administrator acknowledged that such behavior could be perceived as abuse, especially if overheard by a resident. However, the facility did not remove the staff from working with the resident, nor did it conduct a comprehensive investigation. This included failing to collect statements from the involved staff members, interview the resident, or interview other staff or residents who might have witnessed the incident. The facility's inaction left the resident feeling that their concerns were not addressed, and the alleged abusive behavior continued.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for a resident with moderate cognitive impairment. The resident, who was admitted with unspecified dementia, was observed holding a medication cup with pills in her room without staff supervision. The facility had not completed a self-administration of medication assessment for the resident, nor was there a physician order permitting her to self-administer medications. The resident was unsure of the purpose of the pills and requested assistance to cut them, indicating a lack of understanding and potential risk. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine the safety and appropriateness of self-administration of medications. However, the registered nurse admitted to leaving the medications with the resident without following these protocols. The Nursing Home Administrator confirmed that the nurse acknowledged the mistake and reiterated the expectation that medications should not be left with residents unless they have been assessed and have a proper order for self-administration.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with 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.
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.
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 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.
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.
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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