Geneva Lake Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Geneva, Wisconsin.
- Location
- 211 S Curtis St, Lake Geneva, Wisconsin 53147
- CMS Provider Number
- 525565
- Inspections on file
- 20
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Geneva Lake Manor during CMS and state inspections, most recent first.
Surveyors found that two residents with pressure injuries did not consistently receive care as ordered by their physicians. One resident was observed in bed without required Prevalon boots, and staff were unaware of the order or its inclusion in the care plan. Another resident, dependent for all ADLs and with a coccyx wound, was observed in a chair after meals despite orders to be laid down. The DON acknowledged the care plan omissions and the lack of adherence to physician orders.
A resident with bilateral nephrostomy tubes did not receive care as ordered, with observation revealing that both nephrostomy sites were covered with ABD pads instead of the specified dressing materials, and one nephrostomy tube lacked a securement device. The LPN had to apply the securement device during care, and the DON confirmed that securement devices should always be in place and ABD pads should not be used.
A resident with a history of unresponsive episodes after hemodialysis did not receive care consistent with professional standards, as staff failed to communicate with the dialysis center and did not complete required post-dialysis assessments or documentation. The resident returned from dialysis with symptoms such as headache and difficulty speaking, but staff were unaware of the resident's specific monitoring needs and did not follow facility policy for communication and monitoring.
Two residents did not receive their prescribed medications as ordered, including missed doses of a weekly diabetes injection due to unavailability and delayed administration of morning medications, such as insulin and Parkinson's medications, because of staff and medication cart access issues. Documentation inconsistencies were noted, and the DON was unable to provide further explanation for the missed or late doses.
A resident with diabetes and Parkinson's did not receive scheduled insulin doses as ordered, with significant delays and missed administration times. An LPN left the facility, resulting in late medication administration, and insulin was not given according to special instructions or with proper physician notification. Documentation showed insulin was held without a physician order, and the DON could not explain the discrepancies.
An LPN did not follow hand hygiene protocols while providing wound care to a resident with severe cognitive impairment and a stage 3 pressure injury. The LPN failed to perform hand hygiene after cleaning up an incontinence episode, after glove removal, and before handling wound care supplies and dressing changes, as required by facility policy.
A resident with multiple chronic conditions experienced a significant change in condition, including increased lethargy, emesis, and decreased intake, but did not receive timely nursing assessment, monitoring, or documentation. Critical lab results indicating infection were not communicated to the provider, and there was a breakdown in shift-to-shift communication. The resident was later hospitalized with septic shock, respiratory failure, and cardiogenic shock, with no facility documentation explaining the emergency transfer.
A dietary aide, who also worked as an activity aide, did not have a required background check completed within the mandated four-year interval. The oversight was discovered during a personnel file review, with the background check only being completed on the day of the survey rather than within the required timeframe, contrary to facility policy.
Nursing staff, including a CNA and a med tech, lacked documented competencies and required training to safely care for residents. A resident experiencing a change of condition had vital signs taken by a CNA without proof of competency or a licensed nurse assessment, and the med tech responsible for blood draws lacked certification and did not complete required pharmacy-related education hours over three years.
Six residents with or at risk for pressure injuries did not receive timely or comprehensive skin assessments, and wound documentation was often inaccurate or incomplete. Preventive interventions such as repositioning, use of support surfaces, and regular skin checks were inconsistently implemented or not documented. Nutritional recommendations from the RD to support wound healing were not followed for extended periods, and care plans were not always updated or adhered to.
A resident with bilateral nephrostomy tubes was sent to the ED six times for tube dislodgement, malfunction, and infection due to inconsistent implementation of care interventions, outdated care plan elements, and insufficient staff training and competency assessment. The resident experienced repeated complications during transfers and discontinued the use of an abdominal binder due to a rash, while staff were not fully aware of this change or adequately trained in nephrostomy tube care.
The facility did not clearly designate a charge nurse for each shift on its nursing staff schedules over a 30-day period. Staff relied on the presence of the DON, Assistant DON, or Nurse Educator, or contacted an on-call person by phone, but there was no specific charge nurse identified for each tour of duty.
The facility did not fully implement its infection prevention and control program, with incomplete infection surveillance data, missing infection rate calculations, and an inadequate water management plan. Staff failed to use required PPE during wound and incontinence care for several residents under Enhanced Barrier Precautions, and brought treatment carts into resident rooms. There was also a lack of staff understanding and adherence to EBP protocols, and water temperature monitoring did not meet CDC recommendations.
The facility did not ensure that antibiotics were only administered after completing and documenting a McGeer criteria review, as required by its antibiotic stewardship program. Multiple residents received antibiotics for infections, such as UTIs, without evidence in their records that the standard criteria for appropriate antibiotic use were reviewed prior to starting treatment.
The facility did not ensure that pharmacy consultant recommendations regarding unnecessary medications and medication monitoring were addressed by physicians for multiple residents. Pharmacy reports were not consistently included in medical records, and there was no documentation of physician review or action on recommendations such as discontinuing unused PRN medications, updating administration instructions, or monitoring lab work for residents on specific drug regimens.
A dietary aide served food and took food temperatures without wearing a hair net, and food temperatures were not obtained or documented prior to or during breakfast service, contrary to facility policy. These lapses in food safety practices had the potential to affect all residents eating in the common dining room.
A resident was moved to a different room after hospital readmission due to an MRSA diagnosis, but was not given prior written notice, an explanation for the transfer, or a choice of available rooms. The resident, who was cognitively intact, expressed confusion and concern about the move and the handling of personal belongings. Facility staff interviews confirmed a lack of communication, documentation, and adherence to policy regarding the room change.
A resident with a documented preference and care plan to be woken up at 6:30 AM was not consistently assisted to get up at the requested time after returning from a hospital stay. Despite posted reminders and clear instructions, staff did not follow the resident's wishes, impacting the resident's ability to maintain independence and access basic needs. Interviews confirmed the resident's preference was not honored, and staff failed to consistently document refusals.
A resident with multiple medical conditions was found to have an abdominal binder applied as a physical restraint without a physician's order, consent, or documentation of ongoing assessment. The binder restricted the resident's movement and was not properly evaluated or monitored, and staff were unaware the resident had discontinued its use due to a rash. The care plan lacked details on the necessity, duration, and alternatives for the binder.
A resident with multiple mental health diagnoses was admitted without a required Level I PASARR assessment being completed at admission, as mandated by facility policy. The assessment was only performed after surveyor inquiry, with the delay attributed to staff oversight due to workload across several facilities.
A resident with a history of swallowing difficulties experienced a choking episode during a meal, but staff did not immediately notify the physician, update the care plan, or refer to dietary or speech therapy for reassessment. The resident continued to receive meals with large food items and without increased supervision, despite previous signs of swallowing issues. Key team members were not promptly informed, and there was a delay in obtaining further evaluation, leaving the resident at risk for additional choking incidents.
A resident who had an indwelling urinary catheter removed did not receive a comprehensive bladder assessment or an updated care plan to address urinary incontinence. Despite being cognitively intact and able to communicate needs, the resident was left in a soiled incontinence brief and was not provided with appropriate toileting options such as a bedside commode. Staff documented voiding patterns but did not use this information to develop a toileting program, resulting in unmanaged incontinence.
A resident with multiple health conditions experienced significant weight loss and developed a stage 3 pressure injury. The facility did not consistently monitor the resident's weight or implement Registered Dietician recommendations, such as providing supplements and conducting weekly weights. Staff interviews revealed delays and lack of follow-through on dietary interventions, resulting in inadequate attention to the resident's nutritional needs.
A resident with end stage renal disease and severe cognitive impairment did not have consistent communication forms completed and returned between the facility and the dialysis center for multiple dialysis sessions, as required by facility policy. Despite staff describing a process for sending and receiving information with each treatment, several forms were missing from the medical record.
A resident with Parkinsonism and multiple comorbidities did not receive three scheduled doses of Amantadine HCl due to the medication being placed in an overflow area and not located by nursing staff, resulting in missed administrations documented as 'drug/item unavailable.' The resident, who was cognitively intact, reported frequent medication errors, and staff interviews confirmed confusion about medication availability and administration.
The facility did not post required daily nurse staffing information, including census and actual hours worked by RNs, LPNs, and CNAs, in a visible area accessible to residents and visitors. Instead, staffing schedules lacking necessary details were kept inside nurse stations, making them inaccessible to the public and failing to meet regulatory requirements.
The facility failed to provide appropriate care for two residents experiencing medical changes in condition. One resident developed a high fever, erratic pulse, and breathing issues, but there was no evidence of communication with a medical provider, leading to cardiac arrest and death. Another resident experienced blood in their urine after an antibiotic course, with delayed assessment and notification to a medical provider, resulting in a hospital diagnosis of UTI and sepsis. The facility's lack of thorough assessment and communication with medical providers led to significant deficiencies in care.
The facility failed to address grievances for four residents, including issues with medication administration, neglect, and inadequate care. Complaints were not properly documented or investigated, indicating a deficiency in the grievance handling process.
The facility failed to report several allegations of abuse, neglect, and injuries of unknown origin to the NHA and State Agency within required time frames. A resident's neglect allegation was not reported until a grievance was filed, and another resident's injury was reported late. A grievance about long call light response times was not reported as neglect, and a bruise of unknown origin was not reported to the State Agency.
A facility failed to involve an activated POA in a resident's admission and care decisions, despite the resident being deemed incapacitated. The resident signed admission documents without the POA's involvement, contrary to facility policy. The facility did not adequately address the resident's concerns about the POA or ensure a new decision-maker was appointed, leading to a deficiency in care.
A resident with multiple diagnoses, including dementia and on hospice care, had a bruise of unknown origin that was not investigated by the facility until a surveyor raised the issue. The facility's policy requires thorough investigation of all alleged violations, but this was not followed until prompted by external review.
A facility failed to develop timely and individualized baseline care plans for two residents upon admission. One resident, with multiple complex diagnoses, did not have a care plan initiated until four days post-admission. Another resident's care plan lacked personalized interventions, initially documenting generic care approaches. The facility's staff acknowledged these oversights, attributing them to a transition period and inadequate review processes.
A resident with multiple medical conditions was discharged from a facility without a proper discharge plan, resulting in an unsafe transition to home care. The resident, deemed incapacitated, revoked their POA, leaving them without a decision maker. The facility failed to coordinate necessary post-discharge services, leading to the resident being discharged without home health services or medications.
A resident with multiple medical conditions and an activated POA was admitted to a facility, but the POA was not involved in the admission process. The resident revoked the POA, and the facility failed to assist in obtaining a new decision-maker or applying for Medicaid. Family disputes and inadequate discharge planning led to an unsafe discharge, despite recommendations against it.
The facility failed to investigate medication errors involving two residents. One resident received an incorrect potassium dose due to an E-Mar entry error, while another received crushed medications instead of whole, affecting their treatment. Despite notifications and concerns raised, no investigations were conducted to address these errors.
A resident did not receive several prescribed medications over a period of months due to unavailability, as identified by a surveyor through interviews and record reviews. The medications included those for diabetes, blood pressure, gout, glaucoma, depression, GERD, and asthma. The resident reported the issue to staff, who confirmed the medications were not available. The DON acknowledged the problem, citing changes in the medication refill process and ongoing staff education.
Failure to Implement Physician Orders for Pressure Injury Prevention and Care
Penalty
Summary
Surveyors identified that the facility failed to provide necessary treatment and services to prevent and promote healing of pressure injuries for two residents. One resident, who had severe protein-calorie malnutrition, traumatic brain injury, dementia, and was receiving hospice care, had physician orders for Prevalon boots to be worn at all times while in bed due to bilateral heel pressure injuries. However, observations revealed the resident was in bed without the boots, and staff were unaware of the order. The care plan and care card did not reflect the order for Prevalon boots, and the boots were not initially found in the resident's room. Only after inquiry did staff locate and apply the boots, and the Director of Nursing acknowledged the care plan needed updating to include this intervention. Another resident, with vascular dementia, cerebral atherosclerosis, and an unstageable pressure injury on the coccyx, had a physician order to be laid down after all meals. Despite this, the resident was repeatedly observed in a broda chair in common areas after meals, contrary to the order. The wound was noted to be improving, but the facility leadership acknowledged the concern when it was brought to their attention. These findings demonstrate that the facility did not ensure physician orders related to pressure injury prevention and care were consistently implemented for residents at risk.
Failure to Provide Ordered Nephrostomy Tube Care and Securement
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including Parkinson's Disease, Type 1 and Type 2 Diabetes Mellitus, neurogenic bladder, and bilateral nephrostomy tubes, did not receive nephrostomy care in accordance with physician orders and professional standards. The resident's care plan required nephrostomy tube care every shift, and physician orders specified cleansing the insertion site with 1/4 strength Dakins solution, covering with calcium alginate, and then with 4x4 border gauze, ensuring no adhesive was on the tubing. Additionally, the orders required the use of securement devices for the nephrostomy tubes, to be replaced as needed if soiled or losing adherence. During observation, it was found that both nephrostomy sites were covered with a large ABD pad adhered with tape, rather than the ordered dressing materials. Furthermore, the right nephrostomy tube did not have a securement device in place, contrary to the physician's order. The LPN providing care had to obtain and apply the securement device during the observation. The DON confirmed that the nephrostomy tubes should always have securement devices and should not be covered by ABD pads. No additional information was provided by the facility regarding these concerns.
Failure to Ensure Safe and Coordinated Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication and monitoring before and after dialysis treatments. The facility's policy required staff to communicate with the dialysis center before and after each treatment using a designated communication form and to coordinate care plans, including any special considerations and emergency contacts. However, for one resident with a complex medical history—including end stage renal disease on hemodialysis, congestive heart failure, COPD, diabetes with complications, and a history of unresponsive episodes primarily after dialysis—these procedures were not followed. The resident had recently been hospitalized for chest pain and shortness of breath, during which multiple unresponsive episodes occurred, mostly during hemodialysis. Hospital records indicated that these episodes were likely functional neurologic syndrome and recommended close monitoring, with instructions not to send the resident to the hospital unless new symptoms arose. Despite this, the facility did not document the resident's history of unresponsive episodes or the need for additional monitoring after dialysis. On one occasion, after returning from dialysis, the resident complained of a headache, had difficulty speaking, and exhibited abnormal vital signs, but there was no documentation of a post-dialysis assessment or evidence that staff were aware of the resident's specific risks. Review of facility records showed that the dialysis communication form for the relevant date was not completed upon the resident's return, and there was no evidence that staff contacted the dialysis center to obtain a report as required by policy. Nursing staff interviewed were not aware of any special monitoring needs for the resident, and documentation of vital signs lacked time stamps. The lack of communication and failure to follow established procedures resulted in the resident not receiving dialysis care and monitoring consistent with professional standards.
Failure to Administer Medications Timely and Ensure Medication Availability
Penalty
Summary
The facility failed to ensure that prescribed medications were administered to residents in a timely manner, as required by facility policy and physician orders. For one resident with type 2 diabetes, obesity, and COPD, multiple weekly doses of Ozempic injections were not administered because the medication was not available on several scheduled dates across three months. Medication Administration Records (MARs) documented the absence of the medication, and the Director of Nursing (DON) attributed the issue to nurses not ordering medications on time, though no further explanation was provided for the missed doses. Another resident with Parkinson's Disease, type 1 and type 2 diabetes, and an amputation experienced delays in receiving morning medications, including insulin and Parkinson's medications. On the day of surveyor observation, the resident reported only receiving an early morning dose and was still waiting for the remainder of the scheduled medications after breakfast. The delay was due in part to the LPN needing to retrieve medication cart keys after being temporarily absent from the facility. The LPN confirmed that the resident's medications, including insulin, had not been administered on time and had not performed a blood sugar check prior to breakfast. Review of the MAR and physician orders confirmed that several medications were either marked as given on time despite being administered late or were documented as not available. The DON acknowledged awareness of the late administration and high blood sugar reading but could not explain discrepancies in MAR documentation. No additional information was provided regarding the reasons for the late or missed medication administration.
Failure to Administer Insulin According to Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, Type 1 and Type 2 Diabetes Mellitus, and an acquired absence of the right leg below the knee did not receive prescribed insulin medications according to physician orders and facility policy. The resident, who had intact cognition and required insulin therapy, did not receive the scheduled 8 AM dose of Insulin glargine until after 11 AM. Additionally, the resident's Lispro insulin, which was ordered to be administered 15-20 minutes before meals, was not given as directed, and the 8 AM dose was held without a physician order. The resident also did not have a blood glucose check or receive insulin prior to breakfast as required. The sequence of events began when the resident, who typically got up around 5:30 AM, was not out of bed until around 9 AM for reasons that were unclear. The LPN responsible for medication administration had to leave the facility for approximately 15 minutes, and the Director of Nursing (DON) was unable to cover the medication cart due to other responsibilities. As a result, the resident's morning medications, including insulin, were significantly delayed. When the LPN returned, the resident's blood glucose was found to be 300, and the LPN administered the long-acting insulin and made decisions regarding the short-acting insulin without timely physician consultation or adherence to the special instructions for administration relative to meals. Documentation reviewed by the surveyor confirmed that the insulin doses were either late, held without a physician order, or not administered according to the specified timing in the orders. The facility's medication administration policy required medications to be given within one hour of the prescribed time and for any deviations to be documented and communicated appropriately. The DON was unable to explain why the Lispro was marked as held and then given at noon, or why the special instructions for timing with meals were not followed. No additional information was provided to clarify the rationale for these actions.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when an LPN failed to perform required hand hygiene during the provision of wound care to a resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who was on hospice care for dementia and had a stage 3 pressure injury, was observed during a wound treatment procedure. The facility's hand hygiene policy requires hand hygiene before and after resident contact, after glove removal, and before performing aseptic tasks. However, the LPN did not perform hand hygiene after cleaning up an incontinence episode, after removing gloves, or before proceeding with wound care and dressing changes. During the observed procedure, the LPN washed hands and donned gloves before touching the resident, but subsequently failed to perform hand hygiene at multiple required points, including after removing soiled gloves and before handling the wound and dressing supplies. The LPN continued to change gloves and handle both the wound and the resident's environment without performing hand hygiene as outlined in the facility's policy. The deficiency was confirmed through observation, interview, and record review.
Failure to Assess, Monitor, and Communicate Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the Wisconsin Nurse Practice Act for a resident who experienced a significant change in condition. The resident, who had a history of diabetes mellitus, Parkinson's disease, and severe cognitive impairment, became increasingly lethargic, refused food, had a small emesis, and had not had a bowel movement for three days. Despite these changes, there was no documentation of a nursing assessment, including vital signs, at the time of the change in condition. Additionally, there was no documentation of the emesis, administration or results of medication for constipation, or the administration and results of a COVID-19 test, even though these were referenced in a nurse practitioner's note. Laboratory work was ordered and collected, and results showed a critically elevated white blood cell count, which was reported to the facility late in the evening. However, there was no evidence that facility nursing staff acknowledged receipt of these results, notified the nurse practitioner or physician, or monitored the resident for further decline. Interviews with staff revealed a lack of communication between shifts regarding the resident's change in condition and pending laboratory results. Staff on subsequent shifts were unaware of the resident's status or the need for close monitoring, and no vital signs or assessments were documented after the initial change in condition. On the following day, the resident was found to be in severe distress, with altered mental status and respiratory difficulty, and was transferred to the hospital by EMS. Hospital records confirmed diagnoses of septic shock due to a urinary tract infection, acute hypoxic respiratory failure, and cardiogenic shock. There was no documentation in the facility's records prior to transfer explaining the circumstances leading to the emergency call or the resident's deteriorating condition. The lack of assessment, monitoring, documentation, and communication among staff directly contributed to the failure to provide care according to professional standards and the resident's comprehensive assessment.
Failure to Complete Timely Employee Background Checks
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure regarding timely employee background checks for one of eight employees reviewed. Specifically, a dietary aide who was also working as an activity aide did not have an updated background check completed within the required four-year interval. The employee was initially hired with all required background check documentation completed at that time, but no subsequent background check was performed by the four-year deadline as mandated by facility policy. This lapse was identified during a review of personnel files requested by the surveyor. The Director of Nursing acknowledged the oversight when informed, and the Human Resources representative confirmed that background checks are their responsibility. The deficiency was confirmed when the Nursing Home Administrator provided background check forms for the employee that were only completed on the day of the survey, rather than within the required timeframe.
Failure to Ensure Staff Competency and Required Training for Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically a certified nursing assistant (CNA) and a medication technician (MT), possessed the appropriate competencies and skills to assure resident safety and respond to resident needs. The CNA assessed vital signs for a resident experiencing a change of condition without documented proof of competency to collect vitals and without a comprehensive assessment being performed by a registered nurse (RN) or monitoring by a licensed practical nurse (LPN). According to facility policy and job descriptions, CNAs are required to report changes in resident condition to a nurse, and only nurses or trained med techs are permitted to take vital signs in certain situations. Interviews with staff and review of records confirmed that the CNA took vital signs during a change of condition, and there was no evidence of a licensed nurse assessment or documentation of the vital signs in the resident's medical record. Additionally, the MT responsible for blood draws did not have evidence of certification to perform blood draws as required by state regulations. The facility relied on the MT to perform all blood draws, as the contracted laboratory did not provide this service. When requested, the facility was unable to provide documentation of the MT's certification for blood draws, only that the MT had requested transcripts of a completed course. This lack of documentation meant the facility could not demonstrate that the MT was qualified to perform this task. Furthermore, the MT did not complete the required four hours of pharmacy-related in-service education for each of the past three calendar years, as mandated by state guidelines. Review of the MT's education records showed insufficient hours in 2022, 2023, and 2024, with no education provided in 2022 and less than the required hours in subsequent years. The MT did meet the requirement for hours worked, but the deficiency in required education and lack of certification documentation for blood draws affected the facility's ability to ensure safe and competent care for approximately 25 residents in the affected zones.
Failure to Provide Timely and Comprehensive Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the development and worsening of pressure injuries for six residents who either had pressure injuries or were at risk. Multiple residents did not receive comprehensive skin assessments upon admission, and subsequent wound documentation was often inaccurate, incomplete, or missing. For example, one resident was admitted with multiple wounds, but the initial skin assessment was not completed, and subsequent documentation lacked measurements, staging, and descriptions. Wounds were not assessed weekly as required, and there were significant gaps in documentation, with some wounds not being documented for weeks at a time. In several cases, wounds progressed in severity, including deep tissue injuries advancing to unstageable or Stage 4 pressure injuries, and new wounds developed during the residents' stays. Interventions to prevent pressure injuries, such as the use of pressure-relieving mattresses, heel boots, and regular repositioning, were inconsistently implemented or not documented as being in place. Observations revealed that some residents' heels were left on mattresses without proper offloading, and prescribed support surfaces were not always functioning (e.g., an unplugged air mattress). In one case, a resident with limited mobility and a prescribed immobilizer brace did not have evidence of regular skin checks under the device, increasing the risk for device-related pressure injuries. Additionally, care plans and interventions were not always updated or followed, and there was conflicting or unclear documentation regarding wound locations and status. Nutritional interventions recommended by the Registered Dietician (RD) to support wound healing were not implemented in a timely manner, with some recommendations not being followed for over two months. The RD's recommendations for wound healing supplements were documented repeatedly without action, and the RD reported a lack of confidence that their recommendations would be implemented. Overall, the facility did not adhere to its own policies and procedures for pressure injury prevention and management, including timely assessments, accurate documentation, implementation of preventive interventions, and prompt follow-through on interdisciplinary recommendations.
Repeated Nephrostomy Tube Complications Due to Inadequate Care and Staff Training
Penalty
Summary
A deficiency was identified when a resident with bilateral nephrostomy tubes experienced repeated complications, resulting in six transfers to the emergency department within a 120-day period. The resident, who is cognitively intact and has multiple comorbidities including neuromuscular bladder dysfunction and diabetic nephropathy, required specialized care for nephrostomy tubes. The care plan included interventions such as the use of an abdominal binder, regular assessment and documentation of drainage, monitoring for infection, and catheter care. However, the care plan also contained outdated interventions that were not relevant to the resident's current needs, such as references to a Foley catheter and voiding trials. Despite the care plan, the resident experienced multiple incidents of nephrostomy tube dislodgement, malfunction, and infection. Documentation revealed that tubes were frequently pulled out during transfers, particularly with the use of a Hoyer lift, and that staff sometimes improvised solutions, such as attaching a Foley catheter to the nephrostomy tube. The resident also developed infections requiring hospitalization and intravenous antibiotics. Interviews with staff and the resident indicated inconsistent use of the abdominal binder, with the resident discontinuing its use due to a rash, and staff not being fully aware of this change. Training for staff on nephrostomy tube care and safe transfer techniques was limited to verbal discussions and occasional meetings, with no formal competency assessment documented in the facility assessment. Surveyor interviews further revealed that staff had only minimal training on nephrostomy tube care, and that interventions to prevent tube dislodgement were not consistently implemented or updated based on the resident's feedback and clinical needs. The facility's failure to ensure staff competency, update care plans appropriately, and consistently implement interventions led to repeated medical interventions and hospitalizations for the resident.
Failure to Designate Charge Nurse on Each Shift
Penalty
Summary
The facility failed to ensure that a charge nurse was designated for each shift, as required to meet the needs of all residents. Over a 30-day review period, nursing staff schedules did not indicate who was assigned as charge nurse for each tour of duty. When questioned, the nursing scheduler stated that during the day, the DON or Assistant DON were present, and on the PM shift, the Nurse Educator was usually in the building, with an on-call person listed at the bottom of the schedule for contact by phone. However, there was no clear designation of a charge nurse physically present in the building for each shift on the schedules. The facility did not provide further explanation for the lack of a designated charge nurse for each shift.
Infection Control Program Deficiencies and EBP Noncompliance
Penalty
Summary
The facility failed to develop and implement a comprehensive infection prevention and control program, as evidenced by incomplete surveillance data, lack of infection rate calculations, and deficiencies in the water management plan. Outbreak summaries and line lists for COVID-19 and other infections were inconsistent, with mismatched numbers of affected residents and staff, and incorrect outbreak conclusion dates. The infection preventionist acknowledged not calculating monthly infection rates, and the Quality Assessment and Assurance (QAA) committee was only provided with line lists, making it difficult to identify infection trends. The water management plan lacked a detailed description and diagram of the water system, did not include all required team members, and failed to identify control measures and monitoring processes. Water temperature logs showed readings below CDC recommendations, and there was no clear policy for corrective action when temperatures were not met. Multiple residents under Enhanced Barrier Precautions (EBP) due to wounds or indwelling devices did not receive appropriate infection control measures during care. Staff, including registered nurses and certified nursing assistants, were observed performing wound care and incontinence care without donning required personal protective equipment (PPE) such as gowns, despite signage indicating EBP status. Staff also brought treatment carts into resident rooms during wound care, contrary to best practices. Interviews with staff revealed a lack of understanding or adherence to EBP protocols, with some staff unaware of the need for PPE or the reasons for EBP status. The facility's policies and procedures for infection surveillance, EBP, and water management were not fully implemented or followed. The infection preventionist was not consistently involved in the water management team, and documentation for water system control measures was incomplete. Logs for cleaning and sanitizing equipment and fixtures were not always filled out, and the facility's water temperature policy conflicted with CDC guidelines. These deficiencies affected the facility's ability to prevent, identify, report, and control infections and communicable diseases, and to maintain a sanitary environment for all residents.
Failure to Document Antibiotic Stewardship Criteria Prior to Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, potentially affecting all 53 residents. Review of infection surveillance logs revealed that antibiotics were administered to residents without documentation of appropriate use, specifically lacking evidence that the McGeer criteria were reviewed prior to starting antibiotics. The Assistant Director of Nursing (ADON) acknowledged that while the facility aimed to use the McGeer criteria for each resident on antibiotics, this had not been consistently done. Infection surveillance logs for several months showed multiple residents receiving antibiotics without the required documentation of McGeer criteria review. Specific examples included residents diagnosed with urinary tract infections who were started on antibiotics without a completed McGeer criteria review documented in their records. In one case, a resident was prescribed Macrobid following a urine culture, and in another, a resident was switched to ciprofloxacin based on physician orders, but in both cases, there was no evidence that the McGeer criteria had been reviewed prior to antibiotic initiation. The surveyor confirmed with facility leadership that there was no documentation in the medical records to support that the standard of practice for antibiotic stewardship was followed before antibiotics were administered.
Failure to Address Pharmacy Consultant Recommendations for Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary medications, as evidenced by the lack of follow-up on pharmacy consultant recommendations for five residents. For each of these residents, the pharmacy consultant provided monthly medication regimen reviews with specific recommendations, such as discontinuing unused PRN medications, monitoring for drug interactions, and updating medication administration instructions. However, the facility did not obtain or document physician responses to these recommendations, nor did they include the pharmacy reports and responses in the residents’ permanent medical records as required by policy. For example, one resident with dementia, anxiety, and depression had recommendations to discontinue an unused PRN medication and to reevaluate the use of multiple medications known to prolong the QT interval. Another resident receiving an inhaled corticosteroid was recommended to have their order updated to include mouth rinsing instructions to reduce the risk of thrush, but there was no evidence of physician review or order update. Additional residents had recommendations related to discontinuing unused medications, monitoring lab work for those on antiplatelets, and ensuring appropriate monitoring for anticoagulant and antidepressant medications, none of which were documented as addressed by the facility. Interviews with the DON and Administrator confirmed that there was a breakdown in the system for communicating pharmacy recommendations to physicians, and that pharmacy reports were not consistently available in the medical records. In several cases, pharmacy recommendations had to be downloaded and printed upon request, indicating they were not integrated into the residents’ records. The facility was unable to provide evidence that pharmacy recommendations were reviewed or acted upon by physicians, resulting in noncompliance with both facility policy and regulatory requirements for medication regimen review.
Failure to Maintain Food Safety and Hygiene During Meal Service
Penalty
Summary
Dietary staff failed to adhere to facility policy and professional standards regarding food safety and hygiene during breakfast service. A dietary aide was observed serving food and taking food temperatures in the common dining room without wearing a hair net, despite facility policy requiring hair restraints to prevent hair from contacting food. The aide acknowledged she was supposed to wear a hair net at all times while serving food but was not wearing one when observed, stating she had just returned from the restroom and was caught off guard. The aide was later seen wearing a hair net during the same meal service. Additionally, food temperatures were not obtained or documented prior to or during the breakfast service, as required by facility policy. The temperature log for the morning in question had no entries at the time residents were eating, and only one temperature was recorded after the surveyor prompted the aide. The cook confirmed that food temperatures are expected to be taken and documented before and during meal service, and that additional entries should have been present for the breakfast period. These lapses in food safety practices had the potential to affect all residents receiving meals in the common dining room.
Failure to Provide Written Notice and Choice in Room Change
Penalty
Summary
A deficiency occurred when a resident was transferred to a different room upon return from the hospital without being provided prior written notice or an explanation for the room change. The facility failed to take the resident's preferences into account or offer a choice of available rooms, and there was no documentation that the resident or their representative received information about the reason for the transfer. The facility's own policy requires orientation to the transfer, information about the new room and roommate, and written documentation of the process, none of which were followed in this case. The resident, who was cognitively intact and able to make decisions, was readmitted to the facility with a history of MRSA, hemiplegia, Parkinsonism, diabetes with nephropathy, and neuromuscular bladder dysfunction. Upon return, the resident was placed in a new room due to the MRSA diagnosis, but was not given notice or an opportunity to view or choose the new room. The resident expressed confusion and concern about the move, noting that personal belongings and decorations were not promptly transferred and that there was uncertainty about the duration of the room assignment. Interviews with facility staff revealed a lack of clear communication and documentation regarding the room change. Staff members were unsure about the process for organizing the resident's new room and could not provide evidence that the resident had been informed in advance or that their preferences were considered. There was also no documented follow-up on how the resident was adjusting to the new environment, further indicating noncompliance with facility policy and regulatory requirements.
Failure to Honor Resident's Preferred Wake Time
Penalty
Summary
Staff did not follow a resident's documented preference to be woken up at 6:30 AM, as outlined in the care plan and posted reminders. Despite clear instructions in the care plan, including signs in the resident's room and at the nurses' station, the resident was not consistently assisted to get up at the requested time after returning from a hospital stay. Observations by the surveyor on multiple mornings found the resident still in bed or receiving morning care well after the preferred wake time. Interviews with the resident confirmed that their request to be up by 6:30 AM had not been honored since their recent readmission, impacting their ability to maintain independence and meet personal needs. The resident, who is cognitively intact and has a history of insomnia, expressed that being up in their power wheelchair by the requested time is essential for independence, including access to food, water, and medications. Staff interviews revealed inconsistent documentation of refusals and a lack of adherence to the resident's stated preferences. The Director of Nursing acknowledged the issue, noting that refusals should be documented but were not. The deficiency centers on the facility's failure to promote and facilitate the resident's right to self-determination regarding their sleep schedule.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat a medical symptom and did not document ongoing re-evaluation of the need for such restraints. Specifically, a resident with multiple diagnoses, including hemiplegia, Parkinsonism, and diabetic nephropathy, was found to have an abdominal binder in place that restricted freedom of movement and could not be easily removed by the resident. The medical record lacked a physician's order, signed consent, documentation of the binder as the least restrictive alternative, scheduled times for use, and ongoing evaluation of the need for the binder. The resident's Minimum Data Set (MDS) indicated no use of physical restraints, and there was no evidence in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) of monitoring the restraint. Interviews with facility staff revealed that the abdominal binder was implemented to prevent dislodgement of nephrostomy tubes during transfers, but there was no assessment or consideration of the binder as a restraint. The resident reported discontinuing use of the binder due to a rash, and staff were unaware of this change. The care plan referenced the binder for tube placement but did not document the rationale, duration, or alternative interventions. The facility did not provide evidence of a comprehensive assessment or care plan for the use of the abdominal binder as a restraint.
Failure to Complete PASARR Assessment on Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a Pre-Admission Screening and Resident Review (PASARR) Level I assessment for a resident upon admission. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process, regardless of payer source. The resident in question was admitted with documented diagnoses of bipolar disorder, depression, anxiety, and PTSD, as noted in both the facility and hospital records. Despite these diagnoses, there was no evidence that a Level I PASARR was completed at the time of admission. The Medicaid Pending Manager (MPM) confirmed during an interview that she is responsible for reviewing new admissions and completing the Level I PASARR, but acknowledged that the assessment for this resident was not completed until the day of the survey. The delay was attributed to the MPM's workload across multiple facilities, resulting in the oversight. The Level I PASARR was only completed and submitted on the day of the survey, and a Level II PASARR was requested but not yet completed. Facility leadership was made aware of the deficiency during the surveyor's visit.
Failure to Ensure Timely Assessment and Supervision After Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of swallowing difficulties and multiple diagnoses, including neuropathy, dementia, and GERD, experienced a choking episode while eating breakfast. The resident had previously shown signs of coughing and choking during meals and was on a mechanically altered diet. Despite these documented concerns, after the choking incident, nursing staff did not immediately notify the physician or update the resident's plan of care to address the swallowing issue. There was also no immediate referral to the dietician or speech therapy to reassess the resident's dietary needs or supervision requirements. The medical record review revealed that the resident's choking episode was not promptly communicated to the interdisciplinary team, including the dietician and speech therapist. The resident continued to receive meals with larger food items, such as sausage, that were not pre-cut, contrary to previous recommendations. The lack of timely assessment and intervention following the choking incident meant that the resident's risk for further choking was not adequately addressed. Staff interviews confirmed that key team members were not made aware of the incident, and there was a delay in obtaining orders for further evaluation, such as a swallow study and speech therapy assessment. The deficiency was further evidenced by the absence of documentation regarding follow-up actions after the choking event, including the lack of immediate changes to the resident's diet or supervision level. The facility did not ensure that the resident received the necessary care and services to prevent further accidents related to swallowing difficulties. This lapse in care created a situation where the resident remained at risk for additional choking episodes without appropriate safeguards in place.
Failure to Assess and Develop Toileting Program After Catheter Removal
Penalty
Summary
A deficiency occurred when a resident, who previously had an indwelling urinary catheter, did not receive a comprehensive bladder assessment or an updated care plan after the catheter was removed. The facility's policy requires a thorough assessment and the development of a toileting program to restore continence, but this was not completed for the resident. The care plan continued to reference the indwelling catheter even after its removal, and no new interventions or toileting plans were implemented to address the resident's urinary incontinence. The resident, who was cognitively intact and had multiple medical diagnoses including fractures, diabetes, congestive heart failure, and morbid obesity, was observed to be lying in bed with a soiled incontinence brief and an odor of urine. The resident reported not being changed since the previous night and expressed a desire for a bedside commode to avoid urinating in the brief. Staff interviews confirmed that while hourly documentation of voiding and incontinence care was completed, no nurse or nurse manager reviewed this information to establish a toileting program such as prompted voiding. Further interviews revealed that the resident was aware of the need to urinate and could communicate this to staff, but was not offered appropriate toileting options such as a bedside commode or a properly positioned bed pan. The lack of a comprehensive assessment and individualized toileting plan following catheter removal led to the resident continuing to experience unmanaged urinary incontinence.
Failure to Address Resident's Nutritional Needs and Weight Loss
Penalty
Summary
A resident with multiple medical conditions, including a left femur fracture, hemiparesis, polyneuropathy, and cerebrovascular disease, experienced a significant weight loss of 9.2% over a two-month period. The resident was dependent on staff for all activities of daily living and was initially assessed as low nutritional risk, but later developed a stage 3 pressure injury and was identified as high nutritional risk due to wounds. The resident's weight was not consistently monitored, with a missing weight record for one month, and the facility failed to implement recommended interventions from the Registered Dietician (RD), such as providing a liquid protein supplement and conducting weekly weights after the significant weight loss was identified. The RD made several recommendations over the course of the resident's stay, including offering a house supplement daily, obtaining recent and weekly weights, and providing additional protein to support wound healing. Despite these recommendations, documentation shows that the facility did not timely initiate or follow through with the RD's interventions. The care plan included monitoring and recording weight, notifying the healthcare provider and family of significant weight changes, and providing supplements as ordered, but these actions were not consistently carried out. Interviews with staff revealed a lack of clarity regarding facility procedures for obtaining weights and a delay in responding to dietary recommendations. The newly appointed RD confirmed that recommendations should be implemented within 24 hours and noted that the previous RD had reported issues with the facility not responding to or following up on recommendations. The survey team found that the facility did not adequately address the resident's nutritional needs, as evidenced by the unaddressed weight loss and lack of timely intervention.
Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards, specifically regarding communication with the dialysis center before and after treatments. The facility's policy requires staff to communicate with the dialysis center using a designated communication form for each dialysis visit. However, for a resident with diagnoses including dementia, pleural effusion, end stage renal disease, and dependence on renal dialysis, only two dialysis communication forms were found in the medical record for January and February, despite multiple scheduled dialysis sessions during that period. Interviews with staff revealed that the process involves sending an orange folder with the resident containing pertinent information to the dialysis center, which is supposed to return the completed form after each treatment. Despite this process, several communication forms were missing for multiple dialysis dates, and the issue persisted even after the facility administration had discussed the problem with the dialysis center. No additional documentation was provided to account for the missing forms.
Failure to Ensure Resident Free from Significant Medication Errors
Penalty
Summary
A resident with diagnoses including Parkinsonism, MRSA, hemiplegia, type 2 diabetes with nephropathy, and neuromuscular bladder dysfunction did not receive three scheduled doses of Amantadine HCl 100mg, a medication ordered once daily for Parkinsonism. The medication administration record (MAR) documented these missed doses as 'drug/item unavailable' over several days, despite a physician order in place. On one of the days, the medication was signed out as given, but the surrounding missed doses and documentation raised questions about its actual administration. The resident was cognitively intact, able to communicate, and reported to the surveyor that improper medication or dosing occurred at least three times a week, requiring vigilance during medication administration. Interviews with facility staff revealed that the Amantadine HCl had been delivered and placed in an overflow area, but nurses did not check there, resulting in the missed administrations. The medication was not available in the contingency supply, and staff were unclear about the process for locating and administering the medication. There was no further explanation provided as to why the facility failed to ensure the resident was free from this significant medication error, as required by facility policy and physician orders.
Failure to Post Daily Nurse Staffing Information in Visible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data, including the date, resident census, and total actual hours worked by RNs, LPNs, and CNAs, was posted daily in a visible location. Over a review of 30 days, there were no nurse staff postings available, and the facility had no record of such postings being completed or maintained for the past 18 months. When the surveyor requested to see the postings, none were found in the reception area or other visible locations accessible to residents and visitors. Interviews with facility staff revealed that the nurse staffing information was being posted inside the nurse stations, which required entry through a closed door and was not accessible to the public. The information posted was the nursing staff schedule, not the required staffing data, and it lacked pertinent details. Staff acknowledged that this method did not meet the requirements for visibility or content, and the deficiency had the potential to affect all 53 residents currently residing in the facility.
Failure to Address Medical Changes in Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents experiencing a medical change in condition, as per the standards of practice consistent with the Wisconsin Nurse Practice Act. One resident, who had a history of aphasia, hemiplegia, gastrostomy, diabetes, and severe sepsis with septic shock, developed a high fever, erratic pulse, and oxygen saturations, and had rapid gargled breathing. Despite these symptoms, there was no evidence of communication with a medical provider for consultation and treatment. The resident experienced cardiac arrest and passed away in the facility. The lack of medical intervention for the resident's high temperature, gargled breathing, high blood sugar, and erratic vital signs created a finding of immediate jeopardy. Another resident, who had a diagnosis of vascular dementia and a urinary tract infection, experienced blood in their urine after completing an antibiotic course. There was no assessment or notification to a medical provider about the resident's change in condition until several days later. The resident was eventually taken to the hospital by their family and diagnosed with a urinary tract infection and sepsis. The facility's delay in assessing the resident and consulting with a medical provider contributed to the resident's deteriorating condition. The facility's policy required prompt notification of changes in a resident's condition to the attending physician and the resident's representative. However, in both cases, there was a lack of thorough assessment, documentation, and communication with medical providers regarding the residents' changes in condition. This failure to adhere to the facility's policy and the standards of practice for registered nurses resulted in significant deficiencies in the care provided to the residents.
Removal Plan
- All nurses were provided education related to recognition of physiological changes of condition as well as reporting of such changes of condition.
- Education provided includes interventions, notifications and documentation. The education includes review of facility policy and procedure as it relates to condition changes, response to those changes and appropriate notifications to provider.
- Establish a standard for vital signs parameters so that nursing staff call 911 if they are unable to reach a medical provider.
- The Stop and Watch Early Warning Tool Interact tool has been implemented. The tool is available electronically within the EHR and copies have been made and placed in all nursing assistant and ancillary staff work stations.
- All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse.
- Mandatory education is to include agency staff.
- Post tests given following education to ensure competency in both notification and treatment responses as well as when to use the Stop and Watch tool.
- The Change of Condition policy has been reviewed by the DON and with the Medical Director. Modifications include the addition of: Examples of change of condition, Use of Interact tools-Stop and Watch, VS will be taken immediately or as soon as possible with a change of condition. Once VS and immediate assessment is completed, MD will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order.
- All changes of condition will be listed on the 24-hour report board.
- The DON and ADON will review progress notes and 24-hour report board for any changes of condition to ensure all resident condition changes have been identified and action taken in response to resident condition changes.
- Audits will continue and results will be brought to the quality improvement committee for review.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances for four residents, as observed through interviews and record reviews. One resident, who was receiving dialysis, had multiple complaints about medication administration and staffing issues that were communicated by the dialysis center to the facility. Despite these communications, no grievances were recorded or investigated by the facility. The resident's dialysis social worker confirmed that the resident was alert and oriented, and the facility's grievance log showed no entries for this resident. Another resident's Power of Attorney filed a grievance regarding medication administration, which was not thoroughly investigated. The social worker only interviewed the nurse on duty and did not review the medication administration record or interview other witnesses. The social worker assumed there was no issue because the resident was sleeping peacefully, despite the POA's concerns about restlessness and medication administration. A grievance was also filed on behalf of a resident by hospice staff, reporting neglect when the resident was found soiled and wet. The facility did not thoroughly investigate this grievance, as no other residents were interviewed, and staff education was not adequately documented. Additionally, another resident expressed concerns about long call light response times and inadequate care, but the investigation lacked documentation of staff interviews or a resolution plan to prevent recurrence. The facility's failure to properly document and investigate these grievances indicates a significant deficiency in their grievance handling process.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report several allegations of abuse, neglect, and injuries of unknown origin to the Nursing Home Administrator (NHA) and the State Agency within the required time frames. Resident 12 had an allegation of neglect on August 28, 2024, which was not reported to the NHA until September 6, 2024, when a grievance was filed. The allegation was never reported to the State Agency. Resident 12, who was enrolled in hospice services, was found by hospice staff with urine and feces on them and experienced a fainting episode. The registered nurse involved did not recall reporting the concern to anyone, and the assistant nursing home administrator admitted that it did not occur to them to submit a report to the State Agency. Resident 9 was observed with bruising to the left side of their face on August 17, 2024, which was not reported to the NHA, State Agency, or police within the required two-hour window. The resident was cognitively impaired and had a history of cerebral infarction and other conditions. The injury was only reported after the resident returned from the hospital, and the NHA began an investigation. The Director of Nursing acknowledged the delay in reporting and had no additional information to provide. Resident 10 expressed a grievance about long call light response times, which resulted in an incontinent episode. The grievance was not reported to the State Agency as neglect. The social worker involved directed the concern to the appropriate department, but the Director of Nursing did not recall the concern. Additionally, Resident 5 had a bruise of unknown origin on their wrist, which was not reported to the State Agency. The Licensed Practical Nurse who documented the bruise did not report it to anyone, assuming the progress note would suffice. The Director of Nursing was unaware of the bruise until the surveyor's visit.
Failure to Involve Activated POA in Resident's Admission and Care Decisions
Penalty
Summary
The facility failed to allow a resident's representative to exercise their rights as delegated by an activated power of attorney (POA). The resident, who was deemed incapacitated by a physician and a psychologist, was admitted to the facility without the presence of their designated POA, FM-Z. Despite the activation of the POA, the resident signed all admission consents and contracts, which should have been signed by FM-Z. The facility's policy required that the decisions of a resident representative be treated as the decisions of the resident, but this was not adhered to in this case. The resident had a history of multiple medical conditions, including a wedge compression fracture, lung cancer, malnutrition, Parkinsonism, congestive heart failure, atrial fibrillation, emphysema, and peripheral vascular disease. Despite being assessed as incapacitated, the resident was involved in signing various admission documents, including consents for treatment and advanced directives, without the involvement of the activated POA. The facility's failure to involve the POA in the admission process and decision-making was a significant oversight. Throughout the resident's stay, there were multiple instances where the facility did not adequately involve the POA in decision-making processes, including care conferences and discharge planning. The resident expressed a desire to revoke the POA, citing concerns about the POA's intentions, but the facility did not take appropriate steps to address the situation or ensure a new decision-maker was appointed. The facility's inaction in involving the POA and addressing the resident's concerns about their decision-making rights led to a deficiency in the care provided.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for a resident who had an injury of unknown origin. The facility's policy on investigating allegations requires that all allegations be thoroughly investigated, with the administrator initiating the investigation and ensuring that the resident and their representative are informed of the progress. However, in this case, the facility did not initiate an investigation into the resident's bruise of unknown origin until it was brought to their attention by a surveyor. The resident involved was admitted with diagnoses including encephalopathy, vascular dementia, and general anxiety disorder, and was on hospice care. The resident's medical record indicated a bruise on the left wrist of unknown cause, documented by an LPN. Despite the facility's policy, the investigation was only initiated after the surveyor raised concerns during a meeting with facility staff, indicating a lapse in the facility's adherence to its own procedures for handling such incidents.
Failure to Implement Timely and Individualized Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents, R16 and R7, within 48 hours of their admission, as required by their policy. R16 was admitted with multiple diagnoses, including metabolic encephalopathy, vascular dementia, and severe sepsis, and required significant assistance with daily activities. Despite these needs, a baseline care plan was not initiated until four days after admission. The Director of Nursing (DON) acknowledged the oversight, attributing it to a transition period and the absence of an admissions nurse, but confirmed that a care plan should have been in place upon admission. For R7, a baseline care plan was initiated on the third day after admission, but it lacked individualized, person-centered interventions. R7 had complex medical conditions, including a wedge compression fracture, lung cancer, and Parkinsonism, necessitating specific care approaches. The care plan initially documented generic interventions without selecting the appropriate care level based on R7's needs. It was only revised three days post-admission to include personalized care strategies. The Assistant Nursing Home Administrator (ANHA) admitted to not reviewing the care plan closely and agreed that it lacked personalization until revised. The surveyor's findings highlighted the facility's failure to adhere to its policy of creating a baseline care plan within 48 hours of admission, which is crucial for meeting residents' immediate health and safety needs. The lack of timely and individualized care plans for R16 and R7 indicates a gap in the facility's admission process and care planning, as acknowledged by the facility's staff during interviews with the surveyor.
Failure to Ensure Safe Discharge Plan for Incapacitated Resident
Penalty
Summary
The facility failed to ensure a proper discharge plan for a resident, leading to an unsafe transition to home care. The resident, who was incapacitated and had no appointed decision maker, was discharged without home health services or medications. The facility's policy required an individualized post-discharge plan, but this was not effectively implemented for the resident. The resident had a history of multiple medical conditions, including a wedge compression fracture, cancer, and Parkinsonism, and was deemed incapacitated by medical professionals. Despite this, the resident revoked the existing Power of Attorney (POA), leaving them without a designated decision maker. The facility did not adequately address this change in the resident's decision-making capacity, resulting in a lack of coordination for necessary post-discharge services. Interviews and documentation revealed that the facility did not conduct a discharge meeting with the resident's family members, and there was no evidence of a safe discharge plan. The resident was discharged without the necessary support, as home health services could not be initiated due to the absence of a responsible party to sign the admission paperwork. Additionally, the resident did not have access to medications upon discharge, further compromising their safety and well-being.
Failure to Ensure Safe Discharge and Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to ensure the highest practicable physical, mental, and psychosocial well-being for a resident, identified as R7, during the discharge process. R7 was admitted with multiple diagnoses, including a wedge compression fracture, lung cancer, and Parkinsonism, and had an activated Power of Attorney (POA) upon admission. However, the facility did not include the POA in the admission process, nor did they assist R7 in obtaining a decision-maker or guardian after R7 revoked the POA. Additionally, the facility did not assist R7 in applying for Medicaid after a change in payor sources from Medicare, and failed to ensure a safe discharge plan. R7's admission process was flawed as the facility did not involve the activated POA, FM-Z, in the admission paperwork, which was signed solely by R7. Despite being deemed incapacitated by medical professionals, R7 expressed a desire to revoke the POA, citing concerns about FM-Z's intentions and actions. The facility's social worker, SW-I, was involved in discussions with R7 and external parties, including the Ombudsman and Adult Protective Services (APS), but there was confusion and lack of clarity regarding R7's rights and the facility's responsibilities. The facility did not effectively coordinate with the POA or ensure that R7's financial and legal needs were addressed, particularly concerning Medicaid application and discharge planning. The discharge process was further complicated by family dynamics and conflicting interests. R7's family members, including FM-Z and FM-AA, had differing opinions on R7's care and living arrangements, leading to disputes over R7's discharge to home versus an assisted living facility. The facility's failure to secure a clear decision-maker or guardian for R7, coupled with inadequate communication and coordination with family members, resulted in an unsafe discharge plan. Despite recommendations from therapy and medical professionals that R7 was not safe to discharge home, the facility proceeded with the discharge without ensuring all necessary supports and services were in place.
Failure to Investigate Medication Errors
Penalty
Summary
The facility failed to thoroughly investigate medication administration errors involving two residents, R6 and R2. R6 was mistakenly administered 40 milliequivalents of potassium, which was not prescribed for them. The error occurred due to an incorrect entry in the electronic medication administration record (E-Mar) intended for another resident. Although appropriate notifications and monitoring were documented after the error, there was no documentation of the possible cause of the error or interventions to prevent its recurrence. The Director of Nurses (DON) and other facility leaders were unable to provide additional information regarding the investigation of this error. R2, who has multiple diagnoses including type 2 diabetes, end-stage renal disease, and dementia, experienced a medication error when their medications were crushed instead of being administered whole, as required for optimal effectiveness. Despite a progress note indicating that the dialysis center had communicated concerns about R2's medication administration, the facility did not conduct an investigation into the error. The Director of Nursing confirmed that administering crushed medications when whole medications are required constitutes a medication error, yet no investigation was completed following the incident.
Resident Did Not Receive Prescribed Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident, identified as R17, was free from significant medication errors. R17 did not receive several prescribed medications from September 2024 through November 2024 because the medications were not available. The medications that were not administered included Trulicity for diabetes, losartan hydrochlorothiazide for blood pressure, allopurinol for gout, latanoprost for glaucoma, sertraline for depression, Toprol XL for blood pressure, pantoprazole for GERD, and fluticasone for asthma. This deficiency was identified through interviews and record reviews conducted by the surveyor. R17 was admitted to the facility with diagnoses including cellulitis of the abdominal wall, morbid obesity, type 2 diabetes, and COPD. The resident was cognitively intact and independent with eating, bed mobility, and transfers with a walker. During an interview, R17 reported frequently not receiving all prescribed medications and was informed by staff that the medications were unavailable. The Director of Nursing acknowledged the issue, stating that the facility had changed its medication refill process and was providing ongoing education to staff, including agency staff, but did not provide additional information on why the medications were not consistently available to R17.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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