Florence Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Florence, Wisconsin.
- Location
- 5778 Chapin St, Florence, Wisconsin 54121
- CMS Provider Number
- 525358
- Inspections on file
- 23
- Latest survey
- March 8, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Florence Health Services during CMS and state inspections, most recent first.
The facility failed to maintain toilets in a clean and homelike condition when multiple shared-bathroom toilets contained rusty metal strips at the openings or under elevated seats, which several residents reported as bothersome. Residents stated they had informed CNAs, housekeeping, and maintenance about the rust, but these concerns were not reflected in maintenance request logs. A housekeeper acknowledged seeing the rust and hearing resident complaints, and an account manager admitted being aware of the condition but did not report it. An LPN, the DON, and the executive director all confirmed upon observation or interview that the rusty strips were inappropriate and not consistent with a safe, homelike environment.
A resident with vascular dementia, urinary tract issues, and an indwelling catheter experienced a change in condition, including confusion and milky, yellow urine. The care plan required staff to report and document such changes and possible UTI signs. Nursing notes recorded the abnormal urine and later an SBAR entry noted abnormal BP, increased confusion, and new orders for urinalysis/culture and increased fluids, with subsequent transfer to urgent care and hospital admission. However, the DON, who reported contacting a urology department and receiving instructions to send the resident to urgent care, did not document these provider notifications or related details in the medical record, resulting in incomplete documentation of the change in condition and provider communication.
Three residents experienced abuse due to the facility's failure to investigate and implement interventions after an initial altercation involving verbal and physical aggression. The care plan for the aggressive resident was not updated, and staff were unaware of the incident, leading to a subsequent physical assault on another resident. The residents involved had moderate cognitive impairment and other significant medical conditions.
A resident-to-resident altercation involving verbal and physical aggression was not reported to the State Agency as required by facility policy. Both residents involved had moderate cognitive impairment and significant medical histories. The DON was unaware of the full extent of the incident and confirmed that the required report was not made.
Two residents with moderate cognitive impairment were involved in a verbal and physical altercation, including yelling and the use of mobility aids in a confrontation. Despite facility policy requiring immediate investigation of abuse allegations, no thorough investigation was conducted, and the DON was unaware of the incident's extent.
A resident with a history of trauma and multiple chronic conditions did not have a care plan that included specific trauma-related diagnoses, triggers, or individualized interventions, despite assessments identifying these needs. Staff interviews revealed that team members were unaware of the resident's trauma history or how to respond to trauma-related events, and the care plan contained only generic statements. This lack of individualized planning resulted in staff being unprepared to address the resident's trauma needs, especially after a physical assault by another resident.
A resident with diabetes and multiple comorbidities was admitted with hospital discharge orders for scheduled and sliding scale insulin, as well as recommendations for close blood glucose monitoring. The facility failed to transcribe the sliding scale insulin order and did not implement frequent blood sugar checks, resulting in only once-daily monitoring and omission of the sliding scale regimen. Staff interviews revealed confusion about order transcription and monitoring frequency, and the pharmacy did not identify the missing order.
A medication cart containing drugs and biologicals was left unlocked and unattended by an LPN during medication administration, with multiple residents passing by the exposed drawers. Facility policy requires medication carts to be locked when not attended by authorized staff, and both the LPN and DON confirmed this standard was not followed.
A resident with intact cognition reported to staff that a CNA got in their face and refused to provide requested care, which the resident described as abuse. Although the incident was reported internally and to the State Agency, the facility did not notify local law enforcement as required by policy and federal regulations. The NHA was aware of the reporting requirements but did not report the allegation to law enforcement, relying instead on a later conversation with the resident.
A resident with severe cognitive impairment was reported by family to have missing cash from their wallet. The facility investigated by interviewing the resident and family, and searching the resident's room, but could not determine what happened to the money. Despite policy requirements, no staff education or preventative action was taken following the allegation of misappropriation.
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete documentation and delayed reporting of a COVID-19 outbreak. The Infection Preventionist's dual role as a floor nurse hindered proper management, leading to inconsistent symptom tracking for residents. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with wounds or MDROs, further highlighting deficiencies in infection control practices.
The facility failed to ensure the Infection Preventionist (IP) dedicated sufficient part-time hours to manage the infection prevention and control program. An LPN, also working full-time as a floor nurse, was only able to allocate about 2 hours per week to IP duties, leading to an incomplete infection prevention program, as observed by surveyors.
The facility failed to store and prepare food in a sanitary manner, affecting most residents. Food items lacked proper labeling with open and use-by dates, and microwave heating procedures were not followed, as food was not covered or allowed to stand for the required time. Additionally, the temperature of sanitizing solutions was not tested, only the PPMs, contrary to instructions. The Dietary Manager and Registered Dietician acknowledged these oversights.
A resident was unnecessarily administered antibiotics due to the facility's failure to implement its antibiotic stewardship program. The resident was prescribed Bactrim DS for a UTI that did not meet infection criteria, and the culture showed resistance to the antibiotic. The physician was not informed of the culture results, leading to the completion of an ineffective seven-day course. The Infection Preventionist acknowledged the oversight, highlighting a lapse in communication and adherence to the facility's policy.
The facility failed to document the offer or administration of the 2024-2025 COVID-19 vaccine for three residents, as required by their policy. Despite previous declination forms, there was no record of the most recent vaccine offer or refusal, confirmed by the Infection Preventionist.
A resident with a history of stroke and other conditions was hospitalized with a head injury after a fall from a Hoyer lift. During a later hospitalization, hospital staff found a vaginal mucosa tear, leg bruises, and spinal fractures, which the facility failed to report to the State Agency. Interviews revealed staff were unsure about reporting requirements, and no investigation was conducted into the injuries.
A resident in a long-term care facility was hospitalized with a head injury after a fall and later found to have a vaginal mucosa tear, bruises, and compression fractures. The facility failed to investigate these injuries, despite being notified by hospital staff. Interviews with facility staff revealed a lack of awareness and action regarding the new injuries, and no investigation was conducted to determine their cause.
A facility failed to provide proper notification to a resident, their POA, and the Ombudsman regarding hospital transfers. The resident, with a history of stroke and other conditions, was transferred twice without receiving written notices. The DON signed notices on behalf of the resident and POA, but there was no documentation of mailing. Staff were unaware of notification requirements for ED transfers, leading to the deficiency.
A facility failed to provide a resident and their POA with written information about the bed hold policy during hospital transfers. The resident, who had a history of stroke and other medical conditions, was transferred twice without receiving the required notice. Staff were unfamiliar with the policy, and documentation was incomplete, leading to a deficiency in procedural compliance.
A resident's meal preference for French toast was not honored during lunch service, despite multiple requests from staff. The resident, who consistently preferred French toast due to feeling ill with other foods, left the dining area without eating. The facility's failure to update the meal ticket and lack of preparation knowledge contributed to the deficiency.
The facility failed to prepare pureed meals according to standardized recipes, using water instead of broth or gravy, which compromised the nutritional value for two residents. Additionally, one resident did not receive all items listed on their meal ticket, as a pureed cranberry muffin was omitted. These actions were contrary to the facility's dietary policies and procedures.
The facility did not ensure pneumococcal vaccinations were reviewed, offered, or administered to two residents as per CDC guidelines. The medical records lacked declination forms and documentation of vaccine discussions. The Infection Preventionist admitted to not having a system for pneumococcal vaccines, focusing more on COVID-19 and influenza vaccines.
A resident with a history of malignant neoplasm and dysphagia experienced low blood pressure, vomiting, and diarrhea. The facility failed to promptly notify the physician of these changes, despite policy requirements. The resident initially refused hospital transfer, and the physician was only contacted after the resident's daughter intervened. The physician was not informed of the vomiting and diarrhea until later in the day.
A resident undergoing chemotherapy for esophageal cancer did not have a comprehensive care plan addressing increased risks for infection, dehydration, or abnormal lab values. Despite facility policy requiring such plans, the care plan lacked necessary interventions and monitoring guidelines. The DON acknowledged the expectation for a care plan, highlighting a lapse in adherence to care planning processes.
A resident undergoing chemotherapy for esophageal cancer experienced low blood pressure, vomiting, and diarrhea, but the facility failed to conduct a comprehensive assessment of his condition. Despite the facility's policy requiring frequent monitoring, no formal hydration assessment was performed. The resident was eventually transferred to the hospital, where he expired the following day due to neutropenic sepsis.
Failure to Maintain Clean and Homelike Toilet Conditions
Penalty
Summary
The deficiency involves the facility’s failure to maintain residents’ toilets in a clean, safe, and homelike condition as required by its Safe and Homelike Environment Policy. Surveyors observed rusty metal strips at the openings of toilets in the shared bathrooms of four residents. One resident’s toilet had a rusty metal strip at the opening, and the resident reported that it bothered them and that they had informed a CNA and a housekeeper. Another resident was seen exiting a bathroom where the toilet also had a rusty metal strip; this resident stated they did not like the strip and had told staff about it previously. A third resident’s toilet had an elevated seat resting on a rusty metal strip, and this resident stated the strip bothered them and that they had reported it to maintenance a long time ago. A fourth resident’s shared bathroom toilet also contained a rusty metal strip at the opening. Staff interviews and record review showed that these concerns were not acted upon or documented through the facility’s maintenance systems. An LPN initially stated she had not seen rusty metal strips on toilets but, upon observation, acknowledged the condition was not acceptable. A housekeeper reported having noticed a rusty metal strip and said he had placed it on a maintenance clipboard at one time and confirmed residents had complained, noting the rust resembled feces. However, maintenance request logs from several months contained no entries about rusty metal toilet strips. The account manager supervising housekeeping admitted awareness of the rusty strips and acknowledged they were not homelike but had not reported them. The DON stated the strips were attached to toilet handrails and that housekeeping should have reported resident complaints or entered them into the computerized maintenance program, confirming they were not on the maintenance log and that toilets should not contain rusty metal strips. The executive director stated the strips had been present for a long time, were not appropriate, and that she had not been notified of resident complaints.
Failure to Document Provider Communication During Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete medical records and document provider communication during a resident’s change in condition, as required by its Change in Condition of the Resident policy. That policy specifies that documentation must include a description of the change, assessment findings, emergency care provided, provider notification with date, time, conveyed information, and orders received, responsible party notification, and names and titles of employees involved. The resident at issue had vascular dementia, a history of UTI, obstructive and reflux uropathy, benign prostatic hypertrophy with lower urinary tract symptoms, and an indwelling urinary catheter. The resident’s care plan directed staff to report changes in urine amount, color, or odor, and to report signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, or pain/burning to the physician. On the date in question, a nursing progress note recorded that the resident was in the hall with a walker, believed it was time for breakfast, was reoriented and assisted back to bed, and that the indwelling catheter was draining milky, yellow urine. Later that day, an eINTERACT SBAR note documented abnormal blood pressure and increased confusion, and that the provider ordered a urinalysis/culture and increased oral fluids. A physician discharge summary indicated the medical director and family were aware of orders to send the resident to urgent care, from which the resident was admitted to the hospital. The DON reported she was notified of the resident’s condition early that morning, called the urology department to seek an appointment, and later received instructions to send the resident to urgent care, but acknowledged she did not document in a progress note that she notified the physician or the urology department, despite the policy requirement. The ED also stated the resident’s change in condition should have been documented earlier in the day, demonstrating incomplete documentation of the change in condition and related provider communication.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident altercations, for three of five sampled residents. On 9/11/25, an altercation occurred between two residents involving verbal and physical aggression, including yelling, swearing, threats, and physical contact with mobility devices. The care plan for the resident identified as the initial aggressor did not include goals, triggers, or interventions related to aggressive behavior, and the incident was neither investigated nor reported to the State Agency as required by facility policy. Following this, on 9/13/25, the same resident entered another resident's room and physically assaulted them by slapping them multiple times. This second incident was investigated and reported, but the lack of intervention after the first altercation was noted as a missed opportunity to prevent further abuse. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed that they were unaware of the initial incident and acknowledged that it should have been investigated and addressed per policy. The residents involved had significant medical and cognitive conditions, including dementia with behavioral disturbance, cerebral infarction, and other chronic illnesses. Both the Unit Manager and Director of Nursing confirmed that the care plan for the aggressive resident should have been updated immediately after the first incident, and that the failure to do so left other residents unprotected from further aggression.
Failure to Report Resident-to-Resident Altercation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the State Agency as required by its own policy and federal regulations. An altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, which involved verbal and physical aggression, including yelling, swearing, threatening, and pushing mobility devices against each other. The incident was documented in the medical record, and one resident was subsequently moved out of the shared room. However, the Director of Nursing was not aware of the full extent of the altercation and confirmed that the incident was not reported to the State Agency. The facility's policy mandates that all allegations of abuse, neglect, or exploitation be reported to the State Agency and other authorities within specified timeframes, depending on the severity of the incident. Despite this, the altercation between the two residents was not reported, and there was no evidence of a report being made when requested by the surveyor. Interviews with both residents confirmed the occurrence of the altercation, and the Director of Nursing acknowledged the reporting failure during the survey.
Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
A resident-to-resident altercation occurred between two residents, both with moderate cognitive impairment and significant medical histories, including dementia and cerebral infarction. The incident involved verbal and physical aggression, with yelling, swearing, and the use of mobility aids in a physical confrontation. Documentation in the medical record described the altercation, and interviews with both residents confirmed the occurrence, with one resident recalling the argument and physical contact, and the other unable to recall the event. Despite the facility's policy requiring immediate investigation of any alleged abuse, neglect, or exploitation, there was no evidence that a thorough investigation was conducted following the altercation. The Director of Nursing was unaware of the full extent of the incident and confirmed that no investigation had been initiated. This failure to investigate was in direct violation of the facility's own policies and procedures regarding the handling of abuse allegations.
Failure to Develop and Implement Individualized Trauma-Informed Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement an individualized, comprehensive, resident-centered care plan for a resident identified as having trauma. The resident had a history of chronic medical conditions, including COPD, alcoholic polyneuropathy, alcoholic cirrhosis with ascites, type 2 diabetes, and respiratory failure with hypoxia. Despite quarterly assessments indicating the resident experienced trauma related to life-threatening illness and exposure to combat and captivity, the resident's diagnoses list did not include a trauma-related diagnosis, and the care plan lacked resident-specific trauma interventions. The care plan in place contained general statements and non-specific interventions, such as determining triggers and de-escalation preferences, providing a safe environment, and referring to psychology as indicated. However, it did not specify the resident's actual trauma triggers or preferred interventions, even though the resident had communicated these during assessments. Staff interviews revealed that multiple team members, including RNs, CNAs, the DON, the Unit Manager, the MDS Coordinator, and the Social Services Coordinator, were unaware of the resident's trauma history, triggers, or specific interventions. Staff consistently stated that care plans should be personalized and include specific triggers and interventions to guide care, but this was not done for the resident in question. An incident occurred in which the resident was physically assaulted by another resident, resulting in significant distress and ongoing upset for the affected resident. Staff were not aware of how to respond to the resident's trauma or triggers following the incident, as the care plan did not provide the necessary individualized information. The Social Services Coordinator, who had signed off on the trauma assessments, acknowledged that the care plan should have been edited to include the resident's specific trauma and triggers but had not done so. This lack of individualized planning and communication led to staff being unprepared to meet the resident's trauma-related needs.
Failure to Transcribe and Implement Sliding Scale Insulin Order for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to ensure the accurate administration of medication for a resident with multiple complex diagnoses, including type 2 diabetes, coronary artery disease, hypertension, COPD, diabetic foot ulcers with gangrene, cellulitis, and sepsis status post below-knee amputation. Upon admission from the hospital, the resident's discharge summary included orders for scheduled insulin (Lantus and lispro) and a sliding scale insulin regimen, along with a recommendation to monitor blood sugars closely. However, the sliding scale insulin order and the recommendation for frequent blood glucose monitoring were not transcribed into the resident's Medication Administration Record (MAR), and only once-daily blood glucose checks were ordered and performed. Staff interviews and record reviews revealed that the facility's process for transcribing hospital discharge orders was not followed thoroughly. The Director of Nursing (DON) and nursing staff indicated that orders are transcribed from the discharge summary and reviewed by the provider and pharmacy, but the sliding scale insulin order was omitted. Nursing staff were unaware that the sliding scale order was missing, and there was confusion regarding the frequency of blood glucose monitoring. The facility's policies required verification and clarification of transfer orders, but this was not done for the sliding scale insulin order. Further, the pharmacy did not identify the missing sliding scale order during their review, as they only check for discrepancies if a medication appears to be off. The DON acknowledged that the sliding scale should have been clarified and included in the orders, and that there was no process in place for a second nurse to double-check the transcription of admission orders. As a result, the resident did not receive blood glucose monitoring or insulin administration according to the hospital discharge instructions.
Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency occurred when a medication cart was left unlocked and unattended by an LPN during medication administration on multiple occasions. The medication cart, which contained drugs and biologicals, was observed by a surveyor to be left open and unattended in the 200 wing and outside the dining room, with the drawers facing the hallway and exposed during the medication pass. Multiple residents were observed walking or wheeling past the unattended cart, increasing the risk of unauthorized access. The facility's policy, dated January 2023, requires that medication carts remain locked when not in use or when not attended by authorized personnel. During interviews, the LPN acknowledged that the cart should not have been left unlocked and stated that it was usually locked but was forgotten on these occasions. The DON also confirmed that medication carts are required to be locked when unattended.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an allegation of abuse made by a resident. A resident with intact cognition and responsible for their own healthcare decisions reported to staff that a Certified Nursing Assistant (CNA) got in their face and refused to wash them when requested, which the resident identified as abuse. The incident was reported internally and to the State Agency, and the CNA was suspended pending investigation. However, the facility did not notify local law enforcement of the allegation as required by their policy and federal regulations. Interviews and record reviews confirmed that the Nursing Home Administrator (NHA) was aware of the reporting requirements and the two-hour timeframe for reporting allegations involving abuse, but chose not to notify law enforcement. The NHA based this decision on a subsequent interview with the resident, during which the resident reportedly no longer felt the incident was abuse. Despite this, the initial allegation was not reported to law enforcement as required, and the NHA was uncertain about the resident's feelings at the time the incident was first reported.
Failure to Implement Preventative Action After Alleged Misappropriation
Penalty
Summary
The facility failed to ensure preventative action was taken following an allegation of misappropriation of a resident's property. A resident with severe cognitive impairment and multiple medical diagnoses was reported by family members to have missing cash from their wallet. The family regularly counted the resident's money and noticed that two $50 bills were missing over a two-day period. The incident was reported to facility administration, and both the resident and family members were interviewed. The facility searched the resident's room but was unable to locate the missing money. There was disagreement among family members regarding whether the resident may have hidden the money, but no resolution was reached regarding the missing funds. Despite the facility's policy requiring analysis of such occurrences and implementation of preventative measures, including staff education, no staff education related to misappropriation was completed following the incident. The Nursing Home Administrator was unsure if staff education had been provided, and the Director of Nursing confirmed that it had not. The facility did not take further preventative action to address the potential for misappropriation or to prevent recurrence, as required by their own policies.
Inadequate Infection Control and Reporting in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which was evident during a COVID-19 outbreak in September 2024. The facility's documentation was incomplete, lacking necessary details such as symptom tracking, testing, and outbreak response. The Infection Preventionist (IP) was also working as a floor nurse, which limited their ability to manage the infection control program effectively. This resulted in incomplete surveillance documents and inconsistent symptom documentation for five residents who tested positive for COVID-19. The facility did not report the COVID-19 outbreak to the local health department in a timely manner, as required by state regulations. The first staff member tested positive on September 4, 2024, and the first resident on September 5, 2024, but the outbreak was not reported until September 11, 2024. Additionally, the facility experienced an RSV outbreak in March 2024, which was also reported late to the health department. The facility's failure to report these outbreaks promptly was a significant deficiency in their infection control practices. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with wounds or multidrug-resistant organisms (MDROs) as required. One resident with a diabetic ulcer did not have an EBP order or care plan, and another resident with an MDRO had an EBP order but was not placed on EBP. These oversights indicate a lack of adherence to infection control policies and procedures, contributing to the overall deficiency in the facility's infection prevention and control program.
Inadequate Time Allocation for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) dedicated sufficient part-time hours to effectively manage the infection prevention and control program. The Licensed Practical Nurse (LPN) assigned as the IP was also working full-time as a floor nurse, which limited their ability to allocate adequate time to the infection prevention and control responsibilities. The facility's policy required the IP to be employed at least part-time, with hours varying based on the facility's needs, but the LPN was only able to dedicate approximately 2 hours per week to these duties. This was confirmed during an interview with the LPN, who expressed that the time allocated was insufficient for the role's responsibilities. The survey team observed that the facility's infection prevention and control program was not comprehensive, as evidenced by incomplete line lists, lack of symptom tracking, insufficient follow-through on vaccinations, and an incomplete antibiotic stewardship program. These deficiencies were noted during the survey conducted from November 11 to November 13, 2024. The Director of Nursing and the Administrator in Training were present during the interview with the LPN and did not dispute the LPN's statements regarding the inadequate time dedicated to infection prevention and control duties.
Deficiencies in Food Storage, Preparation, and Sanitization Procedures
Penalty
Summary
The facility failed to ensure food was stored and prepared in a sanitary manner, potentially affecting 50 of 53 residents. During a kitchen tour, surveyors observed several food items in the walk-in cooler and dry storage area that were not properly labeled with open or use-by dates, contrary to the facility's policy and the FDA Food Code. Items such as tomato juice, English muffins, bagels, salt, powdered sugar, flour, and sugar were found with only received dates, lacking the necessary open and use-by dates. The Dietary Manager (DM) acknowledged the oversight and admitted to dating errors due to haste. Additionally, the facility did not adhere to safe microwave heating procedures. The Registered Dietician (RD) and DM were observed reheating food in the microwave without covering it, failing to allow the required two-minute standing time for thermal equalization, and not stirring the food to ensure even heating. The RD and DM both acknowledged that the food should have been prepped ahead of time and at serving temperature on the steam table, but did not provide a reason for not observing the two-minute wait time. The facility also failed to test the temperature of sanitizing solutions as required. Although the parts per million (PPM) of the sanitizing solution were recorded, the water temperature was not tested or recorded, as indicated by the crossed-out temperature column on the logs. The DM confirmed that only the PPMs were tested, not the temperature, which is contrary to the manufacturer's instructions for the sanitizing solution. The Nursing Home Administrator expected staff to follow the facility's kitchen policies and procedures, which were not adhered to in this instance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in the unnecessary administration of antibiotics to a resident. The resident, identified as R261, was transferred to the hospital and prescribed Bactrim DS for a urinary tract infection (UTI) that did not meet the facility's criteria for infection. Despite the urinalysis culture indicating resistance to Bactrim DS, the resident completed a seven-day course of the antibiotic without the physician being informed of the culture results. This oversight occurred because the facility's policy for monitoring and updating antibiotic use was not followed. The Infection Preventionist (IP) acknowledged that the physician should have been notified about the culture results, which showed resistance to the prescribed antibiotic. The facility's policy required nurses to communicate lab updates, but this was not done in R261's case. The IP also indicated that the process for coordinating antibiotic stewardship activities involved checking a folder in the Director of Nursing's office or the facility's medical record system, which was not adequately followed. This lack of communication and adherence to the antibiotic stewardship program led to the inappropriate use of antibiotics for R261.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to ensure that three residents, identified as R8, R11, and R29, were offered or received the 2024-2025 COVID-19 vaccine. The facility's policy mandates that residents and staff be educated and offered the COVID-19 vaccine, with proper documentation maintained in their medical records. However, upon review, the medical records of R8, R11, and R29 did not indicate whether they received, were offered, or declined the most recent COVID-19 vaccine. This lack of documentation is contrary to the facility's policy, which requires that each resident's medical record include documentation of vaccine education, administration, or declination. The surveyor's review of the medical records revealed that R8 had a declination form dated April 2020, R11 had one from April 2021, and R29 had one from August 2023. Despite these previous declinations, there was no documentation regarding the 2024-2025 COVID-19 vaccine. The Infection Preventionist confirmed the absence of documentation for these residents, indicating a failure in the facility's process to ensure compliance with their vaccination policy.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident, identified as R15, to the Nursing Home Administrator (NHA) and the State Agency (SA). R15, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, aphasia, gastrostomy status, and osteoarthritis, was transferred to the hospital with a head injury following a fall from a Hoyer lift. During a subsequent hospitalization for aspiration pneumonia, hospital staff discovered a vaginal mucosa tear with dried blood, bruises on the legs, and compression fractures in the thoracic and lumbar spine, none of which were reported by the facility to the SA. The facility's policy on abuse, neglect, and exploitation requires reporting of all alleged violations to the appropriate authorities within specified timeframes. However, the Director of Nursing (DON) indicated that the compression fractures were not reported because the discharge summary did not specifically mention them. The DON acknowledged that an investigation should have been initiated to determine the cause of the fractures and other injuries. Despite being informed by hospital staff about the vaginal tear, the facility did not document or report the injury, and there was no follow-up investigation. Interviews with facility staff revealed a lack of awareness and understanding of the reporting requirements. The DON and Administrator in Training (AIT) were unsure about the suspicion of abuse regarding the fractures, and the Social Worker (SW) failed to document a phone conversation with hospital staff about the vaginal tear. The facility's regional consultant suggested possible causes for the tear but did not confirm any investigation into these possibilities. The NHA did not provide a clear response when asked if the injuries should have been reported to the SA, indicating a gap in the facility's compliance with reporting protocols.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for a resident, identified as R15, who was part of a sample of six residents. R15 was transferred to the hospital with a head injury following a fall from a Hoyer lift and was later hospitalized for aspiration pneumonia. During the hospital stay, R15 was found to have a vaginal mucosa tear with dried blood, bruises on the legs, and compression fractures in the mid and lower back, none of which were investigated by the facility upon R15's return. The facility's policy on abuse, neglect, and exploitation requires immediate investigation of any allegations or suspicions of abuse, neglect, or exploitation. However, the Director of Nursing (DON) acknowledged that the facility did not investigate the compression fractures or the vaginal mucosa tear, despite being notified by hospital staff. The DON admitted that the hospital discharge summary should have prompted an investigation, and the Social Worker (SW) confirmed receiving a call from the hospital about the vaginal tear but failed to document or report it to the nursing staff. Interviews with facility staff, including the Nursing Home Administrator (NHA), DON, and Administrator in Training (AIT), revealed a lack of awareness and action regarding the new injuries discovered after R15's fall. The facility did not conduct interviews with R15 about the injuries, and there was confusion about the responsibility for investigating injuries that may have occurred at the hospital. The regional consultant suggested possible causes for the vaginal tear but confirmed that no investigation was conducted to determine the cause of the injuries.
Failure to Provide Proper Transfer Notification
Penalty
Summary
The facility failed to provide proper notification to a resident, their Power of Attorney (POA), and the State Long-Term Care Ombudsman regarding the resident's transfers to the hospital. The resident, who had a history of stroke, hemiplegia, hemiparesis, dysphagia, aphasia, gastrostomy status, and osteoarthritis, was transferred to the hospital on two occasions. On both occasions, neither the resident nor the POA received a written transfer notice, and the Ombudsman was not notified of one of the transfers. The facility's policy required that transfer notices be provided as soon as practicable and that the Ombudsman be notified via a monthly list. During the survey, it was found that the Director of Nursing (DON) signed the transfer notices on behalf of the resident and POA, indicating phone notification, but there was no documentation of the notices being mailed. A handwritten note suggested that the notice was mailed, but it was not returned. Additionally, the Business Office Manager and Social Worker were unaware of the requirement to provide written notices and notify the Ombudsman for transfers to the Emergency Department (ED) when the resident was not admitted to the hospital. This lack of awareness and documentation led to the deficiency in ensuring proper notification for the resident's transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a resident, identified as R15, and their Power of Attorney (POA) with written information regarding the bed hold policy during two hospital transfers. R15 was transferred to the hospital on two occasions, once after a fall from a Hoyer lift resulting in a head injury and another time due to aspiration pneumonia. Despite these transfers, neither R15 nor their POA received a written notice of the bed hold policy, which includes the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility. The facility's policy requires that such notice be provided at the time of transfer or within 24 hours, but this was not adhered to in R15's case. The surveyor's investigation revealed that the facility's staff, including an LPN and the Business Office Manager, were not familiar with the bed hold policy or the process for providing the notice. The Director of Nursing acknowledged that the forms were not signed by R15's POA and there was no documentation to confirm that the notices were mailed. Additionally, the bed hold forms lacked effective dates and daily rates, further indicating a lapse in the facility's adherence to its own policies. This deficiency highlights a failure in communication and procedural compliance regarding the bed hold policy for hospitalized residents.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to meet the nutritional needs of a resident, identified as R31, by not honoring their meal preferences during a lunch service. The facility's Meal Distribution and Dining and Food Preferences documents outline the procedures for meal assembly and honoring resident preferences, but these were not followed. During the lunch meal, the Dietary Manager (DM-G) and Registered Dietician (RD-H) were responsible for meal preparation. Despite multiple requests from kitchen staff (CK-I) to prepare French toast for R31, RD-H did not fulfill the request, citing a lack of knowledge on how to make the egg batter recipe. Consequently, R31 did not receive their preferred meal and left the dining area without eating. Interviews with staff and the resident revealed that R31 had a consistent preference for French toast at every meal due to feeling ill with other foods. The Dietary Manager acknowledged awareness of R31's preference and admitted that the meal ticket should have been updated to reflect this. The Registered Dietician later discussed meal preferences and nutrition with R31, who confirmed the desire to continue having French toast for every meal. The failure to provide the requested meal led to R31 leaving the dining room hungry, highlighting a lapse in the facility's adherence to its own policies regarding resident meal preferences.
Failure to Follow Dietary Procedures for Pureed Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that conserved the nutritive value for two residents on pureed diets. The kitchen staff did not follow standardized recipes when preparing pureed food items, which is necessary to maintain the nutritional content of the meals. Specifically, during a lunch service, the Dietary Manager (DM) was observed using water instead of broth or gravy to puree meatloaf and green beans, which diluted the nutritional value of the food. This action was contrary to the facility's contracted food service's policy and the guidelines outlined in the position description for the Cook. Additionally, the facility did not provide all the items listed on a resident's meal ticket. One resident, who was on a regular diet with pureed texture and nectar consistency liquids, did not receive a pureed cranberry muffin as indicated on their meal ticket. The Dietary Manager acknowledged the oversight, stating that the muffin was already pureed and available but was not included with the resident's meal due to nervousness. These deficiencies were confirmed through staff interviews and record reviews, highlighting a failure to adhere to established dietary procedures and policies.
Failure to Administer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered to two residents, R29 and R48, as per CDC guidelines. The surveyor found that R29 and R48's medical records did not contain declination forms for pneumococcal vaccines in 2024, nor were there progress notes indicating that the risks and benefits of the vaccines were discussed with them. According to CDC recommendations, R29 should have been given one dose of PCV15, PCV20, or PCV21, and R48 should have received a dose of PCV15, PCV20, or PCV21 at least one year after their last PPSV23 dose, which was administered in 2000. The Infection Preventionist (IP)-F acknowledged the lack of a system in place for pneumococcal vaccines, as the focus was more on COVID-19 and influenza vaccines. IP-F indicated that the facility's Social Worker is responsible for obtaining vaccine declination forms upon admission, but there was no declination form for R48. IP-F also mentioned that if they become aware of a resident needing a pneumococcal vaccine, they contact the pharmacist to verify which vaccine should be administered and then ask the resident if they want the vaccine.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify and consult with a resident's physician when there was a deterioration in the resident's clinical condition. The resident, who had been admitted with diagnoses including malignant neoplasm of the esophagus and dysphagia, experienced symptoms of low blood pressure and weakness. Despite these symptoms, the physician was not consulted immediately. The resident's condition included vomiting and diarrhea, which began in the afternoon and continued until the resident was transferred to the emergency room in the evening. The facility's policy required immediate notification of the physician for any significant change in a resident's condition, especially if the symptoms were acute or marked a significant change from usual symptoms. On the morning of the incident, the Director of Nursing was informed of the resident's low blood pressure and reviewed the nurse's notes. Although the physician was contacted about the low blood pressure, this consultation was not documented in the resident's medical record. The resident initially refused to go to the hospital, and the physician was not consulted again until the resident agreed to be transferred later in the day. The nursing staff did not consult the physician after the onset of vomiting and diarrhea, which were new symptoms for the resident. The Licensed Practical Nurse on the afternoon shift reported that the resident had multiple episodes of vomiting and diarrhea but did not contact the physician until the resident's daughter convinced him to go to the hospital. The physician confirmed that he was not informed of the vomiting and diarrhea until the evening, indicating a lapse in communication and adherence to the facility's policy for notifying physicians of significant changes in a resident's condition.
Failure to Develop Comprehensive Care Plan for Chemotherapy Patient
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was admitted with a diagnosis of malignant neoplasm of the esophagus and was undergoing chemotherapy treatment. The care plan did not address the resident's increased risk for infection, risk for dehydration, or abnormal lab values, which required increased monitoring due to the chemotherapy treatments. This deficiency was identified during a review of the resident's records, which showed multiple abnormal lab values and ongoing chemotherapy treatment without a corresponding care plan to guide staff in monitoring and managing these risks. The facility's policy on comprehensive care plans, revised on 9/23/2022, mandates the development of a care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. Despite this policy, the care plan for the resident in question did not include necessary interventions or monitoring guidelines related to the resident's cancer diagnosis and chemotherapy treatment. The Nursing Home Administrator in training, who was also the Director of Nursing, acknowledged the expectation for such a care plan to be in place, indicating a lapse in adherence to the facility's care planning process.
Failure to Assess Change in Condition
Penalty
Summary
The facility failed to comprehensively assess a resident's medical status following a change in clinical condition. The resident, who had a history of esophageal cancer and was undergoing chemotherapy, presented with symptoms of low blood pressure and weakness. Despite these symptoms, a comprehensive nursing assessment was not conducted from the morning until the resident's transfer to the hospital in the evening. The facility's policy required frequent monitoring and assessment of the resident's condition, which was not adhered to. The resident experienced new symptoms of vomiting and diarrhea during the afternoon shift, yet no comprehensive assessment of hydration status or other vital signs was performed. The nursing staff did not conduct a Dehydration Risk Screener or any other formal assessment to evaluate the resident's condition, despite the facility's policy and the resident's deteriorating state. The resident's daughter eventually convinced him to agree to hospital transfer, but by then, the opportunity for timely intervention had passed. Interviews with facility staff revealed a lack of appropriate response to the resident's condition. The Director of Nursing acknowledged that a comprehensive assessment should have been conducted, particularly after the second bout of diarrhea. The resident's physician was informed of the low blood pressure but was not updated with further assessments or changes in the resident's condition. The resident was eventually transferred to the hospital, where he expired the following day due to neutropenic sepsis, secondary to chemotherapy and esophageal cancer.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
