Fond Du Lac Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fond Du Lac, Wisconsin.
- Location
- 244 N Macy St, Fond Du Lac, Wisconsin 54935
- CMS Provider Number
- 525655
- Inspections on file
- 29
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Fond Du Lac Lutheran Home during CMS and state inspections, most recent first.
A resident with a history of hepatic encephalopathy and moderate cognitive impairment eloped from a facility due to inadequate supervision. Despite being assessed as high risk for elopement and having a WanderGuard, the resident managed to remove the device and leave the facility without staff knowledge. The facility failed to implement effective interventions and supervision, leading to a finding of Immediate Jeopardy.
A resident's bathroom was found with BM soiled cloths on the sink, indicating a failure to maintain a sanitary environment. The resident, who had no cognitive impairment, expressed concerns about cleanliness. A Medication Technician confirmed the improper handling of soiled linens, and the Director of Nursing acknowledged the lack of a specific policy for handling soiled items.
A CNA at the facility did not complete the required 12 hours of in-service training during their anniversary hire year, having only completed 7.25 hours. The training lacked coverage of the QAPI process. Despite communication efforts by the NHA, the CNA did not fulfill the training requirements.
The facility did not have written policies and procedures for a facility closure, potentially affecting all 56 residents. The NHA stated that the facility would follow state regulations but acknowledged the absence of a formal policy.
The facility did not implement its policies for preventing abuse, neglect, and theft by failing to conduct timely background checks for two CNAs. The BID forms for these CNAs were not dated, and there was no proof of completion within the required timeframe. The Assistant Nursing Home Administrator confirmed the issue, and no response was received from Human Resources for clarification.
A resident with a pacemaker was admitted to a facility without a care plan for pacemaker use, leading to a hospital admission after the pacemaker's battery expired. Despite the resident's history of heart issues, the facility did not schedule cardiologist appointments or monitor the pacemaker, resulting in a critical drop in heart rate. Staff interviews revealed a lack of protocol for managing residents with pacemakers, contributing to the oversight.
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving two residents. One resident, with intact cognition, reported verbal abuse by a CNA, but the investigation lacked immediate staff education. Another resident, with moderately impaired cognition, reported missing money, but the investigation was delayed and lacked follow-up on emotional needs. The facility's investigations were incomplete, lacking timely interviews, staff education, and follow-up with the affected residents.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. Observations and interviews revealed that CNA-to-resident ratios were not met, leading to long wait times for call light responses and incomplete care. Residents reported delays in receiving assistance, and staff expressed concerns about being unable to complete tasks due to insufficient staffing. The facility had stopped using agency CNAs, exacerbating the staffing shortages.
The facility compromised the dignity of three residents by serving meals on disposable dishware due to a kitchen staffing shortage. Meals were served in Styrofoam containers with plastic utensils, which residents found difficult to use. The Dietary Manager confirmed the use of Styrofoam was due to staffing issues and acknowledged it was not a home-like option. Residents expressed dissatisfaction, with one keeping silverware in their room to avoid using plasticware.
A facility failed to ensure a resident with a legal guardian had court-ordered protective placement, as required by law. The resident, with severe cognitive impairment and multiple diagnoses, lacked the necessary protective placement paperwork. The social worker was unaware of this requirement and had not secured the placement, although they contacted the Aging and Disability Resource Center for guidance.
A resident with diabetes and dementia was observed self-administering insulin without a documented assessment or physician's order. Despite having intact cognition, the facility failed to ensure the necessary protocols were followed, as confirmed by the DON.
A resident with intact cognition experienced verbal and mental abuse from another resident, who used offensive language and derogatory remarks. Despite staff awareness of the behavior, the facility did not consider it willful abuse, failing to protect the resident from emotional distress.
A facility failed to report an allegation of verbal abuse involving a resident, who was distressed by another resident's offensive language. Despite the facility's policy requiring immediate reporting of abuse allegations, the Nursing Home Administrator was not informed until two days later and decided not to report the incident to the State Agency, concluding it did not constitute willful abuse.
A resident at risk for pressure injuries due to dementia and immobility did not receive the required care as outlined in their care plan. Observations and staff interviews revealed that the resident was left in a recliner for extended periods without repositioning, contrary to the care plan's requirements. Staff were unaware of the repositioning schedule, and the facility lacked a specific policy for repositioning.
A resident with a urinary catheter and neurogenic bladder experienced delays in receiving assistance with ADLs. The resident activated the call light, but a Nurse Extern turned it off without providing care, resulting in a 31-minute wait. The Director of Nursing acknowledged the issue, stating that call lights should remain on until care is delivered.
A resident with COPD had an unsecured oxygen cylinder stored upright in their room closet, contrary to the facility's policy requiring oxygen cylinders to be secured. This was observed by a surveyor and confirmed by staff, including an RN, the Facility Manager, and the DON, yet the issue persisted.
A resident with a history of colectomy and ileostomy did not receive appropriate care, leading to stool leakage due to overfilled bags and ill-fitting supplies. The facility lacked specific care orders and documentation, and staff were unfamiliar with the resident's needs.
A facility failed to assess and care plan the use of bed rails for a resident with severely impaired cognition. The resident, who had an activated POAHC, signed a consent form for bed rail use, which should have been signed by the POAHC. The facility lacked a policy for bed rail use, and the necessary assessment was not completed.
A Nurse Extern improperly disposed of an oxycodone tablet in the trash bin instead of following the facility's policy for controlled drug disposal, which requires the presence of two licensed healthcare professionals and proper documentation. The NE-O retrieved the medication and disposed of it in a drug disposal bottle without a second witness and failed to document the destruction in the narcotic log book.
The facility failed to properly label and date medications for several residents, leading to incorrect dosing and administration times. Observations showed that insulin vials and ophthalmic solutions were not dated when opened, and expired vaccines were found in the medication refrigerator. These actions violated the facility's medication storage policy.
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies. A CNA did not adhere to proper hand hygiene protocols while providing care to a resident with an indwelling catheter. Another CNA did not don appropriate PPE while providing incontinence care to a resident on Enhanced Barrier Precautions (EBP). Additionally, the facility failed to implement EBP for two other residents, one with a gastrostomy tube and another with a stage 4 sacral decubitus pressure injury.
The facility failed to ensure proper treatment and care for a resident with diabetes mellitus by not obtaining detailed physician orders for insulin and blood sugar monitoring, not assessing the resident's ability to self-administer insulin, and not monitoring for signs of hypo/hyperglycemia. The facility also lacked a diabetic management policy.
The facility failed to investigate a fall and implement safety interventions for a resident with intellectual disabilities, bipolar disorder, dementia, and epilepsy. Despite a witnessed fall documented by a Hospice RN, the facility did not complete a follow-up investigation or implement safety precautions, leading to additional falls and injury.
A resident received IV fluids through an implanted port administered by an LPN who was not qualified to perform the procedure. The facility failed to ensure that an RN was present to supervise the LPN, as required by state regulations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as being at high risk for elopement. The resident, who had a history of hepatic encephalopathy, alcoholic cirrhosis of the liver, delirium, anxiety disorder, depression, and a history of falling, was ambulatory and used a walker and wheelchair for mobility. Despite being assessed as having moderate cognitive impairment, the resident was able to cut off a WanderGuard bracelet and elope from the facility without staff knowledge on multiple occasions. The resident's elopement risk was initially assessed as low, but after several incidents of wandering and increased confusion, the risk was reassessed as high. The facility placed a WanderGuard on the resident, but the resident managed to remove it multiple times. On one occasion, the resident left the facility and returned from a local store without staff knowledge. The facility's failure to implement effective interventions and supervision for the resident, despite the known risk and history of elopement attempts, led to the deficiency. Staff interviews and record reviews revealed that the facility did not have adequate measures in place to monitor the resident effectively. The resident's care plan included interventions such as structured activities and frequent checks, but these were not consistently implemented. The facility's lack of immediate and effective response to the resident's elopement risk and behavior resulted in a finding of Immediate Jeopardy.
Removal Plan
- Reviewed the facility's Elopement Prevention Policy and updated elopement protocol.
- Provided all staff education regarding supervision for residents at risk for elopement and steps to take if a resident cuts off a WanderGuard, requests a tool to cut off a WanderGuard, and/or continues to express a desire to leave the unit.
- Removed plaques at each stairwell doorway that contained a code to enter and exit the unit and placed a small label with the door code at the top of the door frame.
- Conducted a thorough sweep of all residents for elopement risk and exit-seeking behavior and ensured care plans were updated with interventions to address exit-seeking/unsafe behavior and/or statements to ensure safety.
- Initiated audits of residents with exit-seeking behavior for proper documentation, effectiveness of interventions, and elopement events. Audit results will be brought to the Quality Assurance Performance Improvement committee for review.
Deficiency in Maintaining a Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for a resident, identified as R5, who was observed with bowel movement (BM) soiled cloths on the bathroom sink. R5, who had no cognitive impairment and was responsible for their own healthcare decisions, expressed dissatisfaction with the cleanliness of the bathroom. The observation was made during a surveyor's visit, and the presence of the soiled cloths was confirmed by a Medication Technician (MT-C) who had assisted with R5's care earlier that day. MT-C acknowledged that soiled linens should not be placed on the sink and should be bagged and taken to the utility room. The Director of Nursing (DON-B) confirmed that the facility's usual practice is to place soiled linens directly in a bag for transport to the utility room, and verified that the soiled cloths should not have been left on the sink. However, the facility lacked a specific policy addressing the handling of soiled items, as the provided Standard Activities of Daily Living (ADL) Protocol did not include instructions on where staff should place soiled items during care. This oversight contributed to the deficiency observed in maintaining a clean and safe environment for the resident.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA-D, completed the required 12 hours of in-service training during their most recent anniversary hire year. CNA-D was hired on August 23, 2023, and by the time of the survey, had only completed 7.25 hours of the required training. This included 2.25 hours of electronic training and attendance at five staff meetings. The training completed did not cover all required topics, specifically missing the Quality Assurance and Performance Improvement (QAPI) process. The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged the deficiency, noting that CNA-D had not completed the online training by the due date and had overdue trainings. Despite efforts to communicate the training requirements through emails, CNA-D did not respond or complete the necessary training. The facility's failure to ensure CNA-D's compliance with training requirements was identified during a review of records and staff interviews conducted by the surveyor.
Lack of Facility Closure Policies
Penalty
Summary
The facility was found to lack policies and procedures for handling a facility closure, which could potentially impact all 56 residents. During an interview, the Nursing Home Administrator (NHA) indicated that the facility would adhere to state regulations in the event of a closure but admitted that there was no written policy in place to guide such an event.
Failure to Conduct Timely Background Checks for CNAs
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and theft by not ensuring thorough and timely background checks for two Certified Nursing Assistants (CNAs), identified as CNA-C and CNA-D. The facility's policy requires screening of employees, including verification of references, certification, and criminal background checks before they are allowed to work with residents. However, during a review, it was found that the Background Information Disclosure (BID) forms for CNA-C and CNA-D were not dated, and there was no proof that these forms were completed within the required timeframe. CNA-C, who was hired in 2004, did not have a BID form completed within the previous four years. Similarly, CNA-D, who was rehired in 2024, also lacked a dated BID form, and there was no evidence that the form was completed prior to or on the date of rehire. The Assistant Nursing Home Administrator confirmed the absence of dates on the BID forms and was unsure of the reason. Despite attempts to contact Human Resources for clarification, no response was received by the surveyor.
Failure to Monitor Pacemaker Leads to Hospitalization
Penalty
Summary
The facility failed to ensure proper care and treatment for a resident with a pacemaker, leading to a significant health event. The resident, who had a history of acute congestive heart failure, symptomatic bradycardia, and sick sinus syndrome, was admitted to the facility with a pacemaker. Despite the resident's moderate cognitive impairment, they were responsible for their healthcare decisions. The facility did not have a care plan in place for the resident's pacemaker use, and there was no follow-up care or scheduled appointments with a cardiologist to monitor the pacemaker's functionality. This oversight resulted in the resident being admitted to the hospital after the pacemaker's battery expired, causing the resident's heart rate to drop to the 30s. Interviews with facility staff revealed a lack of awareness and protocol regarding the management of residents with pacemakers. The Assistant Director of Nursing and other staff members acknowledged that there was no process in place for residents admitted with pacemakers, and the resident's stable vital signs did not alert them to the need for monitoring. The Medical Doctor was aware of the pacemaker but did not ensure follow-up care, and there was confusion about who was responsible for checking the pacemaker. The resident and their family were also noted to have some responsibility, as the pacemaker transmitter from the resident's home was not brought to the facility upon admission.
Deficient Investigation of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving two residents. For the first resident, who had intact cognition and multiple medical conditions including type 2 diabetes and chronic kidney disease, an allegation of verbal abuse by a Certified Nursing Assistant (CNA) was reported. The investigation concluded without including staff education on abuse, neglect, and misappropriation. The Assistant Nursing Home Administrator (ANHA) was unaware that immediate education was necessary following a substantiated abuse allegation, which resulted in the employee's termination. The second resident, with moderately impaired cognition and conditions such as type 2 diabetes and anxiety, reported missing money from their dresser drawer. The investigation into this misappropriation was delayed, with the resident and like residents not interviewed until several days after the report. The investigation lacked documentation of follow-up with the resident regarding their emotional needs, and there was no evidence of staff education or interventions to safeguard the resident's belongings. The ANHA acknowledged the lack of follow-up and resolution, as the facility did not find evidence of theft and the money was not replaced. Overall, the facility's investigations were incomplete, lacking timely interviews, staff education, and follow-up with the affected residents. The deficiencies in the investigation process and the failure to provide immediate education and emotional support to the residents highlight significant gaps in the facility's handling of abuse and misappropriation allegations.
Staffing Deficiencies Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the care needs of its residents, as evidenced by the review of staffing shifts and interviews with residents and staff. The facility's staffing plan, as outlined in the Facility Assessment, was not adhered to on 15 out of 30 shifts reviewed. Specifically, the Certified Nursing Assistant (CNA)-to-resident ratios were not met, leading to delayed response times to call lights and incomplete resident care. Observations and interviews revealed that call lights were not answered in a timely manner, and residents experienced delays in receiving necessary care. One resident, who had a urinary catheter and intact cognition, reported long wait times for call light responses, sometimes resorting to using a cell phone to contact staff. On one occasion, the resident waited 31 minutes for assistance after a nurse extern turned off the call light without providing the requested service. Another resident experienced a 37-minute wait for assistance after activating their call light. These delays in care were corroborated by multiple resident interviews, where concerns were raised about the timeliness and completeness of care, including issues with shower schedules and hygiene maintenance. Staff interviews further highlighted the staffing deficiencies, with CNAs expressing that they often felt rushed and unable to complete tasks adequately due to insufficient staffing levels. The facility had stopped using agency CNAs, which contributed to the staffing shortages. Staff reported being frequently asked to work extra hours and feeling pressured to rush through resident care. The Nursing Home Administrator acknowledged the staffing challenges and the facility's failure to meet the staffing ratios outlined in the Facility Assessment.
Dignity Compromised by Use of Disposable Dishware
Penalty
Summary
The facility failed to maintain the dignity of three residents by serving meals on disposable dishware, specifically Styrofoam containers and plastic utensils, due to a staffing shortage in the kitchen. On the morning of July 8, 2024, breakfast was served in Styrofoam containers, and during lunch, beverages were served in Styrofoam cups. Residents expressed dissatisfaction with the use of plastic utensils, which made it difficult to cut food, and one resident reported that their Cream of Wheat was served cold. Another resident mentioned keeping silverware in their room to avoid using plasticware, which they found difficult to handle due to mobility issues. The Dietary Manager confirmed that the use of Styrofoam was due to insufficient kitchen staff and acknowledged that it was not a home-like option for residents. The manager also stated that regular silverware should be provided unless a resident is on precautions, in which case disposable ware is used. However, the manager was unsure why some residents received plasticware when not on precautions. The use of Styrofoam cups for extra fluids was attributed to the lack of large enough cups, although the manager noted that the kitchen supplied plenty of plastic drink cups and coffee cups to the units.
Failure to Ensure Protective Placement for Resident with Legal Guardian
Penalty
Summary
The facility failed to ensure that a resident with a legal guardian had court-ordered protective placement in the least restrictive environment, as required by law. The resident, who was admitted with diagnoses including unspecified intellectual disability, senile degeneration of the brain, bipolar disorder, and dementia with behavioral disturbance, was severely cognitively impaired and had a guardian as a decision maker. Despite having Letters of Guardianship dated back to 1994, the facility did not have the necessary protective placement paperwork for the resident. The social worker at the facility was unaware of the requirement for protective placement and had not ensured it was obtained, although they had contacted the Aging and Disability Resource Center to inquire about it.
Lack of Assessment and Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R45, had a self-administration of medication assessment or a physician's order to self-administer medication. R45, who was admitted with diagnoses including diabetes mellitus and dementia, had a Minimum Data Set (MDS) assessment indicating intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite this, there was no documented assessment or physician's order authorizing R45 to self-administer insulin. During an observation, a Nurse Extern (NE) was seen drawing up insulin and handing it to R45, who then self-injected the insulin. The Director of Nursing (DON) confirmed that R45 did not have the necessary assessment or physician's order for self-administration of insulin, which was expected to be completed by the staff before allowing such practice.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident, R305, from verbal and mental abuse by another resident, R14. R305, who had intact cognition, reported feeling distressed and emotionally affected by R14's offensive language and behavior. R14, who also had intact cognition, was documented to have used derogatory language towards R305 and other residents, causing emotional distress. Despite being aware of R14's behavior, the Nursing Home Administrator did not consider the altercation between R14 and R305 as willful abuse. Multiple staff members, including registered nurses and a medication technician, confirmed R14's habit of using foul language and making negative comments about other residents within earshot. R14's behavior was documented in a behavior note, and staff interviews revealed that R14 often expressed agitation and made threats towards other residents. The facility's policy mandates immediate reporting of abuse, but the response to R14's behavior did not align with this policy, resulting in a failure to ensure an environment free from abuse for R305.
Failure to Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, R305, to the State Agency as required by their policy. The incident involved a conflict between R305 and another resident, R14, where R14 used offensive language towards R305, causing emotional distress. Despite the facility's policy mandating immediate reporting of abuse allegations, the Nursing Home Administrator (NHA) was not informed of the incident until two days later and concluded that the altercation did not constitute willful abuse, thus not reporting it to the State Agency. R305, who has intact cognition as indicated by a BIMS score of 15 out of 15, reported feeling distressed by R14's behavior, which included derogatory remarks. R14, who also has intact cognition with a BIMS score of 13 out of 15, has a history of physical behavior directed towards others. The facility's failure to report the incident promptly and appropriately reflects a deficiency in adhering to their abuse reporting policy.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Pressure Injuries
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as R50, who was at risk for developing pressure injuries due to dementia and immobility. The care plan included interventions such as routine toileting, skincare for incontinence, repositioning every 2-3 hours, and the use of pressure-reducing devices. However, observations and staff interviews revealed that these interventions were not consistently followed. R50 was frequently observed in a recliner for extended periods without repositioning, contrary to the care plan's requirements. Staff interviews indicated a lack of awareness and adherence to the care plan. A nurse extern and a CNA both acknowledged that R50 was not repositioned as often as required, with the CNA noting that R50 was sometimes left in the recliner all day. The Director of Nursing confirmed that staff should assist R50 with bathroom needs and repositioning every 2-3 hours, but this was not consistently practiced. The facility also lacked a specific policy for repositioning, contributing to the deficiency in care for R50.
Delayed Assistance with ADLs for Resident
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for a resident, identified as R2, who had a urinary catheter and was diagnosed with neurogenic bladder. R2 had intact cognition, as indicated by a BIMS score of 15 out of 15. On two separate occasions, R2 experienced delays in receiving care after activating the call light. On the first occasion, R2 waited 31 minutes for assistance after the call light was turned off by a Nurse Extern (NE-O) who informed R2 that a Certified Nursing Assistant (CNA-N) would assist after returning from break. On the second occasion, NE-O again turned off the call light without providing care, resulting in a delay until CNA-N returned from break to change R2's brief. The surveyor's observations and interviews with R2, NE-O, and CNA-N confirmed the delay in care and the inappropriate practice of turning off the call light before care was provided. The Director of Nursing (DON-B) acknowledged the issue, stating that call lights should remain on until care is delivered and that a 31-minute response time is longer than expected. This deficiency highlights a lapse in the facility's protocol for responding to residents' needs in a timely manner, particularly for those requiring assistance with ADLs.
Unsecured Oxygen Cylinder in Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards for one resident, identified as R14, who was part of a sample of 19 residents. R14, who has a diagnosis of chronic obstructive pulmonary disease (COPD), had an unsecured oxygen cylinder stored upright in their room closet. The facility's policy on the safe use of oxygen, dated 11/8/23, requires that oxygen cylinders be secured in an upright position. On 7/8/24, a surveyor observed the unsecured oxygen cylinder in R14's closet. Subsequent interviews with RN-D, the Facility Manager, and the Director of Nursing confirmed the oxygen cylinder was unsecured and should have been properly secured according to facility policy. Despite these acknowledgments, the surveyor observed the unsecured oxygen tank again on 7/10/24.
Inadequate Ileostomy Care for Resident
Penalty
Summary
The facility failed to provide appropriate ileostomy care for a resident, identified as R12, who had a medical history of colectomy with end ileostomy. R12's care plan did not include ileostomy care, leading to issues such as stool leakage from the ileostomy dressing. The resident reported that the ileostomy collection bag was not emptied in a timely manner over a weekend, causing it to overfill and leak multiple times. Additionally, the facility used ill-fitting ostomy supplies, resulting in further leakage. Nursing notes documented instances of stool leakage and appliance changes due to these issues. The facility lacked specific orders for R12's ileostomy care, and the Treatment Administration Record did not document routine ileostomy care. Interviews with staff revealed a lack of familiarity with R12's ostomy care needs, and the facility did not have a policy on ostomy care. The Assistant Director of Nursing acknowledged that orders for ostomy care were not resumed after R12 returned from a hospitalization, and there was an expectation for staff to document ostomy care, which was not met.
Failure to Assess and Care Plan Bed Rail Use
Penalty
Summary
The facility failed to ensure the proper assessment and care planning for the use of bed rails for a resident, identified as R38. R38 was observed with half rails on their bed, but there was no documented risk assessment for their use. Additionally, a risk versus benefits statement was signed by R38, despite R38 having an activated Power of Attorney for Healthcare (POAHC) due to severely impaired cognition, as indicated by a BIMS score of 5 out of 15. The facility lacked a policy for the use of bed rails, and the Director of Nursing confirmed that the side rail consent and release form should have been signed by R38's POAHC. Furthermore, although there was a side rail assessment available in the electronic medical record, it was not completed for R38.
Improper Disposal of Controlled Drug by Nurse Extern
Penalty
Summary
The facility failed to ensure the proper disposal of a controlled drug for one resident, identified as R22, during a medication administration review. A Nurse Extern (NE-O) was observed disposing of an oxycodone 5 mg tablet, a Schedule IV opioid medication, in the medication cart trash bin. When questioned by the surveyor, NE-O admitted to not knowing why the medication was discarded in such a manner and typically placed discarded medication in a bottle. NE-O retrieved the oxycodone tablet from the trash, along with a gabapentin 600 mg tablet and a methocarbamol 500 mg tablet, and subsequently disposed of them in a Destroyer Drug Disposal bottle without verifying the medication with a second witness. The facility's policy requires that medication destruction occurs in the presence of at least two licensed healthcare professionals, and the destruction must be documented in the narcotic log book. NE-O failed to adhere to these procedures, as there was no second witness present during the disposal, and the destruction of the oxycodone was not documented. This incident highlights a breach in the facility's medication disposal policy, which mandates specific steps to ensure controlled substances are disposed of safely and accurately.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and dated appropriately for six residents during medication administration. Observations revealed that staff administered open and undated medications to these residents, which included tamsulosin HCL, Admelog insulin, gabapentin, and ophthalmic solutions. In one instance, a nurse extern administered the wrong dose of tamsulosin HCL to a resident due to an incorrect label and administered a medication at the wrong time to another resident. Additionally, the insulin vials used for multiple residents were not dated when opened, contrary to the facility's policy. Further inspection of the second-floor medication refrigerator uncovered an open and undated multi-dose vial of octreotide acetate and four syringes of expired influenza vaccine. The facility's policy mandates that medications be labeled with an open date and that expired medications be removed and destroyed. However, these protocols were not followed, as evidenced by the presence of expired vaccines and undated vials in the medication storage area.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Certified Nursing Assistant (CNA)-M did not adhere to proper hand hygiene protocols while providing care to a resident with an indwelling catheter. CNA-M failed to perform hand hygiene between glove changes and did not change gloves between dirty and clean tasks during a bed bath and incontinence care. This was confirmed by the Director of Nursing (DON)-B, who acknowledged the lapse in protocol. Another deficiency was observed with CNA-N, who did not don appropriate personal protective equipment (PPE) while providing incontinence care to the same resident on Enhanced Barrier Precautions (EBP) due to a urinary catheter. Despite the presence of a PPE cart and signage indicating EBP, CNA-N only wore gloves and did not use a gown, contrary to facility policy. DON-B confirmed that staff should don full PPE for residents on EBP. Additionally, the facility failed to implement EBP for two other residents. One resident with a gastrostomy tube did not have appropriate signage or a PPE cart outside their room, and another resident with a stage 4 sacral decubitus pressure injury was not on the facility's EBP list. The DON confirmed these oversights, acknowledging that both residents should have been on EBP with proper signage and PPE availability.
Failure to Monitor and Manage Diabetes Care
Penalty
Summary
The facility did not ensure treatment and care in accordance with professional standards of practice for a resident with diabetes mellitus. The resident's medical record lacked detailed physician orders for insulin and blood sugar monitoring, and there was no assessment for the resident's ability to self-administer insulin or perform accuchecks. Additionally, the facility failed to monitor the resident's insulin use and blood sugar levels or check for signs and symptoms of hypoglycemia or hyperglycemia. The resident's care plan indicated that staff should monitor for these signs, but there was no documented proof of such monitoring in the medical record. The resident was admitted with an insulin pump and had a discharge summary that included an order for Humalog but no orders for blood sugar monitoring. The medical record did not contain insulin pump orders or orders for the frequency of blood sugar monitoring. The Director of Nursing confirmed that the facility did not assess the resident for diabetic management and that there were no documented records of the resident's insulin use or blood sugar results. The facility also lacked a diabetic management policy, which contributed to the oversight in monitoring and managing the resident's diabetes care.
Failure to Investigate and Prevent Falls
Penalty
Summary
The facility did not ensure a fall was thoroughly investigated to determine root cause, implement appropriate interventions to prevent reoccurrence, or ensure the environment was as free from accident hazards as possible for one resident. On 3/19/24, a Hospice RN documented that the resident had a witnessed fall, but the facility did not complete a follow-up investigation or implement safety precautions to prevent further falls. The resident subsequently experienced additional falls on 3/23/24 and 3/27/24, with the latter resulting in a 1-inch reddened area on the forehead. The facility's Falls policy, reviewed on 6/24/22, mandates preventative measures to reduce falls and injuries, including completing a Fall Incident Report, updating care plans with identified interventions, and conducting follow-up assessments. However, the facility failed to adhere to this policy for the resident, who had a history of intellectual disabilities, bipolar disorder, dementia with behavioral disturbances, and epilepsy. The Assistant Director of Nursing acknowledged that the facility did not complete a fall investigation or implement safety interventions following the initial fall on 3/19/24.
LPN Administered IV Fluids Without Proper Qualifications
Penalty
Summary
The facility did not ensure that intravenous (IV) therapy treatment was administered by competent staff for one resident. On 11/18/23, an LPN administered IV fluids to a resident through the resident's implanted port, despite not being qualified to do so. The resident had been admitted with diagnoses including malignant neoplasm of the brain and protein-calorie malnutrition and had moderate cognitive impairment. The LPN administered the IV fluids without the direct supervision of an RN, as required by Wisconsin State Legislature Chapter N 6, which mandates that LPNs perform acts in complex patient situations under the direct supervision of an RN or provider. The Director of Nursing (DON) confirmed that the LPN was IV certified but not trained to access central lines, such as implanted ports. The facility's contracted pharmacy's Registered Nurse Educator (RNE) also verified that the certification courses did not cover central lines, as LPNs are not allowed to access them in Wisconsin. On the day of the incident, an RN was not present in the facility during the PM shift when the LPN administered the IV fluids. The DON acknowledged that an RN manager or the previous DON should have come in to administer the order, highlighting a lapse in ensuring proper supervision and competency in IV therapy administration for complex patient situations.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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