Four Winds Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Verona, Wisconsin.
- Location
- 303 S Jefferson St, Verona, Wisconsin 53593
- CMS Provider Number
- 525656
- Inspections on file
- 20
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Four Winds Manor during CMS and state inspections, most recent first.
Two CNAs observed a large bruise on a resident's left upper arm but did not report it as required by facility policy. The injury, later identified as a non-displaced left humerus fracture, was only reported by another CNA on the following shift to an LPN, who then followed protocol. This delay resulted in the incident not being immediately reported to supervisory staff or authorities.
A resident with Parkinson's disease, identified as a fall risk, experienced a fall resulting in a bloody nose when required fall prevention interventions—such as a floor mat and accessible call light—were not in place as specified in the care plan. Staff interviews confirmed that these interventions were expected but not implemented at the time of the incident.
A resident with dementia was found with a bed sheet wrapped around her midsection in a wheelchair by a CNA during the night shift, allegedly to prevent falls. Despite being advised by an RN that this could be considered a restraint, the CNA proceeded, believing it was necessary for safety. The facility's investigation confirmed the use of the bed sheet as a restraint, which was not in line with the resident's care plan or physician orders.
A facility failed to document a baseline care plan within 48 hours for a resident admitted with orthostatic hypotension, atrial fibrillation, and hypertension. Instead, a care card for CNAs was used, which was not the mandated plan to be shared with the resident or their representative. The Administrator and DON could not locate the baseline care plan, leaving initial care expectations unaddressed.
A CNA failed to follow proper hand hygiene protocols during the care of a resident with an indwelling urinary catheter. Despite multiple glove changes due to the presence of fecal matter, the CNA did not perform hand hygiene between glove changes, even after touching various surfaces. The Director of Nursing confirmed that the expectation was for staff to perform hand hygiene before and after each glove change.
The facility failed to provide residents with food and drink at safe and appetizing temperatures, affecting all 33 residents. Residents from all hallways reported receiving cold meals, and test trays confirmed that food temperatures did not meet policy standards. The Dietary Manager acknowledged challenges in maintaining food temperatures during delivery, leading to lukewarm meals that sometimes required reheating.
The facility did not ensure snacks were offered at bedtime when there was more than a 14-hour gap between supper and breakfast, affecting all residents. Staff indicated snacks were available but not routinely offered unless requested. The Nursing Home Administrator and DON acknowledged the need to offer snacks under these circumstances.
Surveyors found deficiencies in food storage and labeling practices at a facility, with multiple instances of food being improperly labeled and expired items in circulation. Staff interviews revealed unclear responsibilities for monitoring and discarding expired food, affecting the safety and quality of food for all 33 residents.
The facility failed to conduct and document routine diabetic foot checks for residents with diabetes, as required by professional standards. Interviews with nursing staff revealed confusion and inconsistency in performing and documenting these checks, with some staff unaware of the need to use a filament for sensation testing. The Director of Nursing believed checks were being completed daily, but there was no documentation to support this.
The facility's infection prevention and control program was found deficient due to missing lab reports and culture and sensitivity results for residents on antibiotics for UTIs. The Director of Nursing relied on doctors' prescriptions without verifying lab results, and the Wound Nurse did not obtain lab results if they were not included in hospital paperwork. This led to uncertainty about whether residents were on the correct antibiotics.
A resident reported an allegation of abuse to her daughter, who informed the facility. Despite conducting a full investigation and suspending the suspected staff member, the facility failed to report the allegation to the State Agency as required by policy. The resident, who is cognitively intact, alleged that a caregiver pushed her onto the bed and twisted her arm, causing injury.
A resident with pressure injuries did not receive timely wound care upon re-admission to the facility. The facility failed to assess the resident's wounds for six days and missed 13 dressing changes over two months. The resident reported difficulties in receiving wound care, and staff interviews confirmed a lack of adherence to wound care orders and communication between shifts.
Two residents experienced significant weight loss due to the facility's failure to maintain nutritional status and notify the physician. One resident, with conditions including cerebral infarction and dysphasia, lost over 5% of body weight in 30 days without timely physician notification or adequate dietary adjustments. Another resident lost 7.97% of body weight in 30 days, with no physician consultation documented. The facility did not follow its policies on weight monitoring and physician notification, leading to inadequate communication and documentation of the residents' nutritional needs.
A facility failed to develop a comprehensive care plan and policy for a resident requiring dialysis, lacking specific emergency procedures for hemodialysis access site issues. Staff interviews revealed uncertainty in handling such emergencies, with CNAs unsure of appropriate actions. The RN indicated that pressure should be applied and 911 called, but the care plan and facility policy did not include these interventions. The DON acknowledged these deficiencies, and no emergency instruction sign was found in the resident's room.
The facility did not ensure timely physician visits for two residents, who missed required 30, 60, and 90-day visits after admission. One resident with multiple diagnoses, including atrial fibrillation and diabetes, missed a 60-day visit, while another with cerebral infarction and hypertension missed both 60-day and 90-day visits. The DON was unsure of the visit status and the facility lacked a policy for physician visits.
The facility failed to thoroughly investigate an allegation of neglect reported by a Med Tech, who found residents soaked and unattended. Key statements were not obtained, residents were not interviewed, and comprehensive staff training was not provided, highlighting significant gaps in the facility's response.
Failure to Immediately Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately to the administrator and appropriate authorities, as required by facility policy and state law. On 10/27/25, two CNAs observed a large bruise on a resident's left upper arm while providing care after dinner. Despite facility policy mandating immediate reporting of such injuries to the supervisor, both CNAs did not report the bruise. The injury was not brought to the attention of supervisory staff until the following shift, when another CNA observed the bruise and reported it to an LPN, who then followed protocol. Further investigation revealed that the resident had sustained a non-displaced left humerus fracture. The facility's policy, dated 8/25, specifies that all injuries of unknown origin must be reported immediately to the Director of Nursing or Administrator, and that all allegations must be reported to the Department of Quality Assurance within specified timeframes. The Nursing Home Administrator confirmed during interview that the initial CNAs failed to report the injury as required, resulting in a delay in notification and investigation of the incident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, who was identified as being at risk for falls, did not have required fall prevention interventions in place as outlined in their care plan. The resident's care plan specified that a floor mat should be placed next to the bed and that the call light should be within reach before leaving the room. On the date of the incident, the resident was found lying face down on the floor beside the bed with a bloody nose, and it was documented that neither the floor mat was present nor the call light within reach at the time of the fall. Interviews with facility staff, including CNAs and an RN, confirmed that fall interventions are communicated through care plans and CNA care cards, and that these interventions are expected to be in place for residents at risk of falling. The Nursing Home Administrator also acknowledged that staff are expected to follow the care plan and that the interventions for this resident were not implemented at the time of the incident.
Resident Restrained with Bed Sheet for Convenience
Penalty
Summary
The facility failed to ensure the rights of a resident, identified as R4, to be free from physical restraints imposed for convenience. R4, who had a diagnosis of dementia and severe cognitive impairment, was found with a bed sheet wrapped around her midsection while in her wheelchair. This action was taken by a Certified Nursing Assistant (CNA1) during the night shift, allegedly to prevent R4 from falling out of the wheelchair. The facility's policy clearly states that residents have the right to be free from any physical restraint not required to treat the resident's symptoms, and there was no physician order or care plan indicating the need for such a restraint for R4. The incident was reported to the Director of Nursing (DON) by a night nurse, RN1, who observed CNA1 using the bed sheet as a restraint. Despite being advised by RN1 that this could be considered a restraint, CNA1 proceeded with the action, believing it was necessary for R4's safety. CNA1's actions were witnessed by another CNA, who reported the incident to a supervisor. The facility conducted an investigation, which included interviews with staff members and a review of the incident. CNA1 admitted to using the bed sheet but claimed it was not tied and that R4 was able to move freely. The facility's investigation concluded that the use of the bed sheet constituted a restraint, as confirmed by witness statements and CNA1's own account. The incident was reported to the state survey agency, and the facility's investigation was deemed inconclusive. However, the facility acknowledged that CNA1's actions were inappropriate and not in line with the resident's care plan or physician orders. CNA1 was suspended pending further investigation, and the facility recognized the need for re-education on the use of restraints.
Failure to Document Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide documentation of a person-centered baseline care plan within 48 hours of admission for a resident, identified as R8, who was admitted with diagnoses including orthostatic hypotension, atrial fibrillation, and hypertension. The facility's policy required the creation of an Initial Resident Baseline Care Plan upon admission, but this was not documented for R8. Instead, a hand-written care card, intended for use by CNAs, was found in the resident's closet. During interviews, RN2 confirmed that this care card was not the mandated baseline care plan that should be shared with the resident and/or their representative. The Administrator and the DON acknowledged that R8's baseline care plan could not be located, and it was unclear if initial care expectations were addressed and communicated to R8 and their representative.
Infection Control Deficiency in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the care of a resident with an indwelling urinary catheter. The Certified Nurse Aide (CNA4) was observed performing peri-care for the resident without following the facility's hand hygiene policy. Although CNA4 initially performed hand hygiene before donning gloves, she did not perform hand hygiene after doffing gloves and before donning new ones during multiple glove changes. This occurred despite the presence of fecal matter, which necessitated several glove changes to ensure the resident was clean. During the care process, CNA4 also touched her pocket, a paper towel, and the door of the resident's room without performing hand hygiene before donning new gloves. This lack of hand hygiene continued throughout the care, including after applying nystatin powder to the resident's peri-area and assisting in moving the resident from the bed to a wheelchair. The CNA confirmed the omission of hand hygiene during an interview, and the Director of Nursing stated that the expectation was for staff to perform hand hygiene before and after each glove change.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that residents received food and drink at a palatable and safe temperature, affecting the entire census of 33 residents. Observations and interviews revealed that residents from all three hallways expressed concerns about food being served cold. The facility's policy on food temperature was not adhered to, as evidenced by test trays and resident feedback. The Resident Council minutes from May to July 2024 documented repeated complaints about cold food, and residents requested meetings with the Dietary Manager and Nursing Home Administrator to address these issues. Specific examples include residents with varying cognitive statuses reporting that their hot meals were often served cold. Test trays ordered by the surveyor showed that food temperatures did not meet the facility's policy standards, with hot dogs served lukewarm and salads not cold enough. The Dietary Manager acknowledged the ongoing issue with maintaining food temperatures and noted that the timing of meal delivery and the effectiveness of tray covers were problematic. The surveyor's observations confirmed that food temperatures were not maintained during delivery, with fried eggs and bacon served at lukewarm temperatures, necessitating reheating in the microwave.
Failure to Offer Bedtime Snacks
Penalty
Summary
The facility failed to ensure that snacks were offered to residents at bedtime when there was more than a 14-hour gap between the evening meal and breakfast. This deficiency was identified through observations, interviews, and record reviews, affecting all 33 residents across three units. Residents expressed concerns during a Resident Council Task meeting about not being offered snacks at bedtime. The facility's posted meal times indicated a 15.25-hour gap between supper and breakfast, which necessitated the provision of bedtime snacks. Interviews with various staff members, including CNAs, an RN, the Dietary Manager, the Nursing Home Administrator, and the Director of Nursing, revealed that snacks were available but not routinely offered to all residents at bedtime. Staff members consistently indicated that snacks were only provided if residents specifically requested them. The Nursing Home Administrator and the Director of Nursing acknowledged that snacks should be offered to all residents when there is more than a 14-hour interval between meals, but this practice was not being followed.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage, labeling, and monitoring of food items. During an inspection, surveyors observed multiple instances of food being removed from original containers without being labeled with an open date. This included items such as coffee, noodles, and various cereals. Additionally, expired food items were found in circulation within the facility's kitchenette, including coffee, prune juice, thickened tomato juice, and cheerios, all past their expiration dates. Furthermore, 29 yogurts were found in the kitchenette refrigerator with expired dates. Interviews with staff, including the Dietary Manager, a CNA, and an RN, revealed a lack of clarity and enforcement regarding the responsibility for monitoring and discarding expired food items. The Dietary Manager indicated that it was the responsibility of all staff to date and label food in the shared kitchenette and to discard expired items. However, the presence of expired and unlabeled food suggests a failure in implementing these policies effectively, potentially affecting the safety and quality of food provided to all 33 residents in the facility.
Failure to Conduct and Document Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that residents with diabetes received routine diabetic foot checks in accordance with professional standards of practice. This deficiency was identified for four residents, all diagnosed with type 2 diabetes mellitus, who had no documentation of diabetic foot checks in their medical records. The facility's policy required diabetic foot checks upon admission and quarterly or upon significant change in condition, but there was no evidence that these checks were being performed or documented. Interviews with nursing staff revealed a lack of clarity and consistency regarding the performance and documentation of these checks, with some staff unaware of the requirement to use a filament for sensation testing. The surveyor's interviews with various nursing staff, including RNs, LPNs, and the Wound Nurse, highlighted confusion and inconsistency in the implementation of diabetic foot checks. Some staff believed checks were supposed to be done daily, while others were unsure of the procedure or documentation requirements. The Wound Nurse indicated that CNAs were previously tasked with performing foot checks, although they are not qualified to assess. The Director of Nursing was under the impression that checks were being completed and documented daily, but this was not the case, as confirmed by the lack of documentation in the Treatment Administration Record (TAR).
Inadequate Infection Control Program Due to Missing Lab Reports
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the lack of proper documentation and follow-up on lab reports and culture and sensitivity (C&S) reports for residents on antibiotics. Specifically, the facility's infection control line lists did not include necessary lab reports for residents diagnosed with urinary tract infections (UTIs), resulting in uncertainty about whether the residents were on the correct antibiotics. This deficiency was observed in one sampled resident and three supplemental residents, who were placed on antibiotics without the facility obtaining their urine culture and sensitivity results to confirm the appropriateness of the prescribed antibiotics. Interviews with the Director of Nursing (DON), who also serves as the Infection Preventionist, and the Wound Nurse (WN), who handles admissions, revealed a lack of a clear process for obtaining lab results when residents are admitted from or return from the hospital. The DON admitted to relying on doctors' prescriptions without verifying lab results, while the WN stated that she only has lab results if they are included in the hospital paperwork and does not reach out to obtain them otherwise. This lack of a systematic approach to ensuring residents are on the correct antibiotics contributed to the deficiency in the facility's infection prevention and control program.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R4, to the State Agency within the required timeframe. R4, who is cognitively intact with a BIMS score of 14 out of 15, reported to her daughter that a caregiver had pushed her onto the bed, causing injury to her hip, and twisted her arm. This incident was reported by R4's daughter to the Director of Nursing (DON B) on July 25, 2024. Despite conducting a full investigation, including staff and resident interviews, and suspending the suspected staff member, the facility did not report the allegation to the State Agency as required by their policy. The facility's policy mandates that all allegations of abuse must be reported to the State Agency immediately or within 24 hours, or within 2 hours if the incident involves serious bodily injury. However, in this case, the DON B acknowledged receiving the report of abuse from R4's daughter but failed to report it to the State Agency. The surveyor's interview with DON B revealed that the DON was unaware of the requirement to report the allegation, despite the facility's policy clearly stating the obligation to do so. This oversight resulted in a deficiency in the facility's compliance with state reporting requirements for abuse allegations.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure injuries, as required by professional standards of practice. Upon re-admission, the resident's wounds were not assessed for six days, contrary to the facility's policy that mandates a wound assessment within 24 hours of admission or re-admission. The resident, who had a deep tissue injury on the right heel and a stage 2 pressure injury on the left heel, reported challenges in receiving wound care, missing at least four dressing changes in a month due to the unavailability of nursing staff. The facility's Medication/Treatment Administration Record indicated that the resident missed 13 dressing changes over a two-month period. Interviews with the LPN and DON revealed that the facility did not adhere to the wound care orders, and there was a lack of communication and follow-through between shifts to ensure the resident's wound care was completed. The DON acknowledged the failure to perform the required wound assessments and treatments, describing the situation as unacceptable.
Failure to Maintain Nutritional Status and Notify Physician
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, leading to significant weight loss without timely physician notification. Resident R25, admitted with conditions including cerebral infarction and dysphasia, experienced a weight loss of over 5% within 30 days. Despite initial dietary assessments identifying weight loss as a concern, the facility did not provide additional calories or identify R25's food preferences to facilitate better oral intake. The physician was not notified of significant weight changes, and the resident's nutritional supplements were inconsistently managed. Resident R29 also experienced significant weight loss, with a 7.97% decrease in body weight over 30 days. The facility failed to notify the physician of this weight loss, and there was no documentation of physician consultation regarding the weight changes. Despite a care conference, there was no mention of the resident's meals or weights, and the resident was discharged without the necessary weight monitoring instructions being included in the discharge paperwork. The facility's policies on weight monitoring and physician notification were not followed, as evidenced by the lack of timely updates to the physician and the absence of documented consultations. The Registered Dietician and nursing staff did not adequately communicate or document the residents' nutritional needs and preferences, contributing to the residents' continued weight loss and the facility's failure to address these issues effectively.
Deficiency in Dialysis Care Planning and Emergency Procedures
Penalty
Summary
The facility failed to develop a comprehensive care plan and policy and procedures consistent with professional standards of practice for a resident requiring dialysis care. The resident, who receives renal dialysis three times a week, did not have a care plan that included necessary care and treatment approaches for dialysis, particularly in emergency situations related to the hemodialysis access site. The facility's policy on hemodialysis care lacked specific interventions for emergent care, such as applying pressure if the resident was found to be bleeding from the dialysis access site. Interviews with staff revealed a lack of knowledge and preparedness for handling emergencies related to the resident's dialysis access site. Certified Nursing Assistants (CNAs) were unsure of the appropriate actions to take if the resident was found bleeding from the fistula, with one CNA stating she would activate the call light and find a nurse, while another was uncertain but thought she would seek a nurse. A Registered Nurse (RN) indicated that staff should apply pressure and call 911 in such situations, and that any staff member, including CNAs, could and should apply pressure. The Director of Nursing (DON) acknowledged the absence of specific interventions in the care plan and facility policy, and it was noted that there was no sign with emergent instructions in the resident's room, contrary to what the DON believed.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter, as required. This deficiency was identified for two residents, R14 and R25, out of a sample of 16. R14, who was admitted with diagnoses including atrial fibrillation, type 2 diabetes, major depressive disorder, osteomyelitis, and heart failure, was not seen by a physician in July, missing a 60-day visit after admission. Similarly, R25, admitted with diagnoses of cerebral infarction, hypertension, and dysphasia, was not seen by a physician in June or July, missing both 60-day and 90-day visits after admission. During an interview on August 6, 2024, the Director of Nursing (DON B) was unable to confirm whether R14 and R25 were current with their required physician visits. Although DON B acknowledged the expectation for physician visits at designated intervals, the facility was unable to provide a policy for physician visits when requested by the surveyor.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that steps were taken to prevent further potential abuse. Med Tech D reported an allegation of neglect, stating that CNA C did not toilet or change residents during her shift, resulting in residents on the D-Wing being soaked. The facility failed to obtain statements from both Med Tech D and CNA C, did not interview any residents, and did not provide training to all staff to ensure this does not occur again. This lack of thorough investigation and follow-up is a clear deficiency in the facility's response to the allegation of neglect. The facility's self-report indicates that CNA C worked her normal shift and was assigned to B-Wing, while CNA E was assigned to A-Wing and could not assist with D-Wing due to quarantine precautions. Med Tech D arrived at 2:00 AM and found residents on D-Wing soaked, indicating that they had not been changed for an extended period. Despite this, the facility did not document any negative effects reported by the residents and concluded that CNA C did not intentionally neglect her duties. However, the facility's investigation was incomplete as it did not include statements from key individuals or interviews with the affected residents. R4, a resident with a BIMS score of 15 indicating cognitive intactness, reported being left wet for extended periods on multiple occasions, including the incident in question. Despite this, the facility did not include R4's account in their self-report. The facility's failure to obtain necessary statements, interview residents, and provide comprehensive staff training highlights significant gaps in their investigation process and response to allegations of neglect.
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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