Green Bay Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Bay, Wisconsin.
- Location
- 1640 Shawano Ave, Green Bay, Wisconsin 54303
- CMS Provider Number
- 525342
- Inspections on file
- 26
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Green Bay Health Services during CMS and state inspections, most recent first.
Two residents did not receive timely or consistently documented wound care for existing pressure injuries and wounds. One resident's wound dressings were not changed for several days after admission and wound care orders were delayed, with further missed dressing changes after orders were in place. Another resident's wound care was not documented as completed on a specific day, with the LPN later stating the care was done but not recorded. These actions did not align with facility policy for wound assessment and treatment.
A contracted hairstylist provided monthly services to residents and was paid by the facility without a required background check being completed prior to starting work, contrary to facility policy. The omission was identified when surveyors requested documentation, and the NHA confirmed the background check should have been done before the hairstylist began providing services.
Staff did not date or label open insulin pens and blood glucose test strips in two medication carts as required by facility policy. Three insulin pens for two residents and two containers of blood glucose test strips were found open and undated. Both an RN and an LPN confirmed the items should have been dated, and the DON acknowledged that the lack of dating would prevent staff from knowing expiration dates.
A facility licensed for 125 beds did not employ a qualified full-time social worker, as neither the Social Services Director nor the Social Services Coordinator met state licensing or experience requirements. Leadership confirmed that both staff members lacked the necessary credentials, potentially impacting multiple residents.
A resident's guardian reported suspected financial exploitation by a previous guardian who was also a staff member. Although the facility documented the allegation and updated the care plan to restrict the staff member's access, the required report to the State Agency was not made, despite ongoing investigations by police and APS.
A resident's guardian reported concerns of financial exploitation by a previous guardian who was also a staff member. Although the facility was aware of the allegation and placed restrictions on the staff member's access to the resident, no internal investigation was conducted and the incident was not reported to the State Agency as required by facility policy. Interviews and documentation confirmed staff awareness of the allegation, but the Nursing Home Administrator did not initiate an investigation.
A resident with severe cognitive impairment and multiple medical conditions was repeatedly observed with an uncovered catheter drainage bag in direct contact with the floor, contrary to facility policy requiring catheter bags to be covered and not touch the floor. The DON confirmed that proper procedures were not followed.
A resident with complex medical needs, including renal dialysis and diabetes, was not weighed according to physician orders or facility policy, with an eight-day gap after admission. The facility also used an outdated weight from a previous admission for dietary assessment and dialysis communication, rather than current weights, as confirmed by the nursing home administrator.
A resident with moderate cognitive impairment was found with medication left at bedside hours after the scheduled administration, despite staff documentation that the medication had been given. The resident reported staff left the medication for self-administration, but there was no physician order or assessment authorizing this. Staff interviews revealed inconsistent practices, and facility policy prohibiting this action was not followed.
A resident with severe cognitive impairment was admitted under a temporary guardianship that expired, but the facility continued to allow the former temporary guardian to make healthcare decisions after the expiration. Despite being informed that the resident was their own decision maker, the facility did not obtain updated legal documentation and permitted the former guardian to act as the resident's representative.
A resident with severe cognitive impairment was allowed to execute a Power of Attorney for Health Care (POAHC) after their temporary guardianship expired, without a formal assessment of capacity. The POAHC was witnessed by staff who were not certified Social Workers as required by state law, and the facility did not ensure permanent guardianship was established before the temporary guardianship lapsed.
A facility failed to manage a resident's financial affairs properly, closing an Irrevocable Burial Trust (IBT) account and withdrawing $7,509 without notifying the resident's POA. The facility's policy requires written authorization for withdrawals and quarterly statements to be provided, which were not done. Additionally, the facility did not pay the resident's monthly care costs to the MCO, resulting in an overdue amount exceeding $10,000. The lack of communication and financial management led to the deficiency.
The facility did not follow its policy to prevent abuse and neglect by failing to conduct thorough background checks for two Business Office Managers. The checks, required by the facility's policy, were missing DOJ and IBIS letters for the staff members, as confirmed by the NHA.
The facility failed to complete neuro checks post-fall for three residents as per policy, leading to a deficiency. Residents with cognitive impairments and fall risks experienced unwitnessed falls, but neuro checks were often missing or delayed. Staff interviews revealed confusion about the timing and completion of neuro checks, particularly with agency staff.
The facility did not implement its abuse policy by failing to conduct out-of-state background checks for a CNA hired earlier in the year. Despite the policy requiring comprehensive checks, the CNA's file lacked these checks, even after an audit and process improvement plan were conducted.
The facility failed to complete PASRR Level II Screens for several residents with mental disorders or intellectual disabilities, despite indications from Level I Screens and the use of psychotropic medications. This oversight affected the assessment and care planning for these residents, as the necessary evaluations were not conducted after the initial 30-day county exemption period.
A resident reported feeling unusually chilled, but the facility did not complete an appropriate assessment or notify the physician timely. The resident was later diagnosed with sepsis. Additionally, the facility failed to consistently provide wound care as ordered, with multiple instances of missed treatments documented.
A resident with diabetes and severely impaired cognition did not receive routine nail care as per the facility's policy. Observations showed the resident's nails were overgrown and unclean, and staff interviews confirmed that nail care was neglected for several weeks.
A resident with cerebral palsy, epilepsy, and anxiety did not have pharmacy recommendations acted upon by a physician. The facility's policy required action within 30 days, but reviews on two occasions were not addressed. The Nursing Home Administrator confirmed the oversight and missing documentation.
The facility failed to monitor high-risk medications for two residents, leading to a deficiency in medication management. One resident on divalproex for epilepsy and another on insulin for diabetes had care plans lacking monitoring for adverse reactions or side effects, contrary to the facility's policy.
A CNA failed to perform hand hygiene after glove removal during incontinence care for a resident, violating the facility's infection control policy. The CNA handled soiled items and moved between tasks without washing hands, as confirmed by the ADON.
The facility failed to ensure adequate reconciliation of controlled medications across all four units, affecting 12 residents. The nurse-to-nurse controlled substance count verification forms were not consistently filled out, as required by the facility's policy. Missing signatures were observed on multiple dates and shifts, indicating that the required counts were not performed or documented properly.
The facility failed to thoroughly investigate an allegation of neglect involving an RN who was found sleeping during their shift and appeared to be under the influence. The RN did not sign out morning medications for residents, and the facility did not identify or rule out potential misappropriation of medication, resulting in an incomplete investigation.
The facility did not have a qualified Social Worker, affecting all 69 residents. The Social Services Director and Social Services Coordinator lacked degrees in social work or related fields and did not have one year of supervised social work experience in a healthcare setting. The Nursing Home Administrator confirmed the previous Social Worker left in January 2024 and was certified with the State of Wisconsin.
Failure to Provide Timely and Documented Wound Care for Two Residents
Penalty
Summary
Two residents did not receive appropriate care and services to promote healing or prevent the development of pressure injuries. One resident was admitted with pressure injuries on the coccyx and deep tissue injuries (DTIs) on both heels. Upon admission, there were no wound care orders in place, and staff did not change the resident's coccyx and heel dressings for seven days. Wound care orders were not initiated until several days after admission, and even after orders were obtained, dressing changes for the coccyx and heels were missed on multiple documented occasions. The initial skin assessment also lacked measurements of the wounds, and the care plan was not fully implemented as wound care was not consistently provided as ordered. Another resident with wounds on the right great toe, right heel, and coccyx had wound care orders in place, but documentation of wound care completion was missing for one day. The DON confirmed that wound care should have been completed and documented as ordered, but the responsible LPN stated that the care was performed but not documented at the time. The facility's policy requires a head-to-toe evaluation upon admission, prompt notification of the primary care physician, and initiation of appropriate treatment orders, which were not consistently followed for these residents.
Failure to Complete Required Background Check for Contracted Hairstylist
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not ensuring a thorough caregiver background check was completed for a contracted hairstylist. According to the facility's policy, all potential employees, contracted staff, volunteers, and consultants must undergo background, reference, and credentials checks, with documentation maintained as proof. However, when the surveyor requested background check information for a sample of staff, it was found that the hairstylist's background check was not completed prior to providing services, and the hire date was not documented. The only available documentation was a Background Information Disclosure form dated after the surveyor's request, with no evidence of a state background check conducted beforehand. Interviews with the Nursing Home Administrator (NHA) confirmed that the hairstylist was not considered an employee, and therefore, a background check was not initially completed, despite the individual being paid by the facility and providing services to residents since the previous year. The NHA acknowledged that, per facility policy, a background check should have been completed before the hairstylist began working with residents. The hairstylist also confirmed providing monthly services to residents and being compensated by the facility.
Failure to Date and Label Insulin Pens and Glucose Test Strips
Penalty
Summary
Surveyors found that staff failed to properly label and date medications and medical supplies in accordance with facility policy and professional standards. Specifically, three insulin pens used for two residents in the 400 wing medication cart were open and undated, and an open container of blood glucose test strips in the same cart was also undated. In the 200 wing medication cart, another open and undated container of blood glucose test strips was observed. Staff members, including a registered nurse and a licensed practical nurse, confirmed during the survey that these items should have been dated when opened. The facility's policy requires insulin pens to be labeled with the resident's name, physician's name, date dispensed, type of insulin, dosage, frequency, and expiration date, and to be disposed of after 28 days or per manufacturer recommendations. The Director of Nursing verified that without proper dating, staff would not be able to determine when medications or supplies expired. These lapses in labeling and dating had the potential to affect more than four residents in the facility.
Lack of Qualified Social Worker in Facility Exceeding 120 Beds
Penalty
Summary
The facility, licensed for 125 beds, failed to employ a qualified full-time social worker as required. The Social Services Director (SSD) held a master's degree in Mental Health Counseling and a bachelor's degree in Psychology, but was only licensed as an Associate Counselor in Arizona and not in Wisconsin. The SSD was in the process of obtaining a Wisconsin license but had not yet completed the necessary coursework. The Social Services Coordinator (SSC) had a degree in Health Care Administration and experience in behavioral intervention, but was not certified as a social worker in Wisconsin and did not have a year of supervised social work experience in a healthcare setting prior to employment at the facility. Interviews with facility leadership confirmed that neither the SSD nor the SSC met the qualifications outlined in the job description for a Social Services Director, which required a bachelor's degree in social work or social welfare, at least one year of experience in a healthcare setting, and a current state license as a social worker. The Nursing Home Administrator acknowledged that both staff members lacked the necessary credentials and that the facility did not have a qualified social worker on staff, potentially affecting more than 4 of the 61 residents residing in the facility.
Failure to Report Alleged Misappropriation to State Agency
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident to the State Agency (SA) as required by policy. The incident involved a resident with mild cognitive impairment, congestive heart failure, and type 2 diabetes, who had a guardian. The resident's current guardian reported concerns about potential financial exploitation by a previous guardian, who was also a facility staff member. Documentation showed that the facility was aware of the allegation, as evidenced by progress notes and care plan updates restricting the previous guardian's access to the resident. The facility's policy required immediate reporting of such allegations to the SA and other authorities, but no facility-reported incident was found for this case. Interviews with the resident's current guardian, facility staff, and the Nursing Home Administrator confirmed that the facility was informed of the allegation and that the previous guardian was accused of stealing money from the resident. The guardian had also reported the matter to police and Adult Protective Services (APS), and there was an active investigation. Despite this, the facility did not report the allegation to the SA within the required timeframe, resulting in a deficiency for failing to follow mandated reporting procedures for suspected misappropriation.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving a resident with mild cognitive impairment, congestive heart failure, and type 2 diabetes. The resident's current guardian reported concerns that a previous guardian, who was also a facility staff member, may have financially exploited the resident. Although the facility's policy requires immediate investigation and reporting of such allegations, there was no evidence that an internal investigation was conducted or that the incident was reported to the State Agency. Interviews with the resident's guardian, facility staff, and the Nursing Home Administrator confirmed that the facility was aware of the allegation, and documentation showed that restrictions were placed on the previous guardian's access to the resident due to concerns about money. However, the Nursing Home Administrator stated that no investigation was initiated because they were unaware of the specific allegation, despite progress notes indicating staff awareness. Further review revealed that the Business Office Manager and former Nursing Home Administrator both acknowledged that an investigation should have occurred if misappropriation was suspected. Communications between the facility, Adult Protective Services, and the resident's guardian confirmed that the issue was discussed and that external agencies were involved. Despite this, the facility did not follow its own policy to conduct an immediate internal investigation or report the allegation, resulting in a deficiency related to the facility's response to alleged violations.
Failure to Maintain Proper Catheter Bag Position and Coverage
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed multiple times with their uncovered catheter drainage bag in direct contact with the floor. The observations occurred on three consecutive days, with the catheter bag either hanging from the bed and touching the floor or resting directly on the floor. The facility's Catheter Care Policy requires that catheter drainage bags be covered or shielded at all times and not be in contact with the floor, in order to maintain appropriate catheter care and resident dignity. The resident involved had significant medical conditions, including dementia, weakness, malignant neoplasm of the prostate, hemiplegia, urinary retention, and overactive bladder, and was assessed as being dependent for transfers, hygiene, dressing, and eating, with severe cognitive impairment. The Director of Nursing confirmed during an interview that catheter bags should not be placed on the floor and should be kept in a clean basin or have something underneath to prevent floor contact. Despite these requirements, the resident's catheter bag was repeatedly found uncovered and in contact with the floor.
Failure to Monitor and Record Resident Weight per Physician Orders and Policy
Penalty
Summary
The facility failed to monitor and record a resident's weight according to both physician orders and facility policy. Specifically, the resident, who had diagnoses including dependence on renal dialysis, critical illness myopathy, and type 2 diabetes mellitus with hypoglycemia and coma, was not weighed for eight days after admission, despite orders requiring weights on admission, daily for two days, weekly for three weeks, and then monthly. The facility's policy also required weights to be measured on admission, the next two days, and weekly for three additional weeks, with all weights recorded in the electronic health record. The nursing home administrator confirmed that these procedures were not followed for this resident. Additionally, the facility used an outdated weight from a previous admission, recorded over a year prior, to complete the resident's dietary assessment and to communicate with the dialysis provider. The resident's care plan identified them as being at risk for nutritional status changes due to infection and end stage renal disease, with interventions requiring weight monitoring and notification of significant changes. Despite this, the most recent and accurate weights were not used in clinical assessments or communications, as evidenced by the documentation reviewed by the surveyor.
Failure to Ensure Safe Medication Administration for Resident Without Self-Administration Order
Penalty
Summary
Staff failed to ensure the accurate and safe administration of medication for one resident with moderate cognitive impairment and a history of refusing medications. On the morning of the survey, medication was observed on the resident's bedside table hours after the scheduled administration time, despite documentation indicating the medication had been given. The resident reported that staff left the medication for self-administration, but the resident forgot to take it. The resident's medical record did not contain a current physician's order or assessment authorizing self-administration of medication, and a previous assessment indicated the resident should not have medications left at bedside due to a tendency to forget or mishandle them. Interviews with staff revealed inconsistent practices regarding medication administration. The medication technician who documented administration could not explain why the medication was found in the resident's room or why the resident reported being left to self-administer. Another LPN confirmed that leaving medication at bedside was not permitted for this resident, as the resident was not assessed as capable of self-administration. The facility's policies require staff to remain with residents until medication is swallowed and prohibit leaving medication in a resident's room without proper assessment and orders, which were not followed in this instance.
Failure to Ensure Healthcare Decisions Made by Legally Authorized Representative
Penalty
Summary
The facility failed to ensure that the right to make healthcare decisions for a resident was extended only to those legally authorized, as required by state law. A resident with severe cognitive impairment, as indicated by a BIMS score of 6 out of 15, was admitted with a court-ordered temporary guardianship that expired after a set period. Despite the expiration of the temporary guardianship and the absence of documentation for permanent guardianship, the facility continued to allow the former temporary guardian to make healthcare decisions for the resident. Medical records and social services notes confirmed that the temporary guardian was involved in signing admission agreements, vaccine consents, and making referral requests after the guardianship had lapsed. Staff interviews and record reviews revealed that the facility was aware the temporary guardianship had expired and that the resident was legally their own decision maker at that time. However, the facility did not obtain updated guardianship paperwork or ensure that only a legally authorized representative made healthcare decisions for the resident. The social services director acknowledged that the former temporary guardian continued to act as the resident's legal representative and decision maker after the expiration of the guardianship, contrary to legal requirements.
Failure to Ensure Proper Guardianship and POAHC Procedures for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide medically-related social services to ensure a resident achieved the highest practicable level of well-being. A resident with severe cognitive impairments, as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15 and multiple diagnoses including hemiplegia, schizophrenia, and cognitive communication deficit, was admitted with a court-ordered temporary guardianship. The facility did not ensure that permanent guardianship was established before the expiration of the temporary guardianship, resulting in a lapse in legal decision-making authority for the resident. Following the expiration of the temporary guardianship, facility staff determined that the resident was their own healthcare decision maker and proceeded to complete a Power of Attorney for Health Care (POAHC) document with the resident. However, there was no assessment conducted to confirm the resident's cognitive ability to comprehend and execute the POAHC document, despite the resident's documented severe cognitive impairment. Staff relied on brief interactions and the resident's momentary clarity, but did not perform or document a formal assessment of capacity. Additionally, the staff member who witnessed the resident's signature on the POAHC document was not a certified Social Worker as defined by Wisconsin State Statute, which is a requirement for employees of the facility serving as witnesses to such documents. Both the Social Services Director and Social Services Coordinator lacked the necessary certification, and this was confirmed by the Nursing Home Administrator. The facility did not have documentation to support that the witnessing staff met the legal requirements, nor that the resident's capacity to execute the POAHC was properly evaluated.
Failure to Safeguard Resident's Financial Affairs
Penalty
Summary
The facility failed to ensure the proper management and safeguarding of a resident's financial affairs, specifically concerning an Irrevocable Burial Trust (IBT) account. The resident, who had intact cognition and was assisted by a Power of Attorney (POA) for financial decisions, had an IBT account opened with the facility. However, the facility closed this account and withdrew the entire balance of $7,509, exceeding the Medicaid-allowed maximum value of $4,500 for such accounts. This action was taken without notifying the resident's POA, which is a violation of the resident's rights to manage their financial affairs. The facility's Business-Resident Trust Fund policy requires that all disbursements and withdrawals from a trust fund must be authorized in writing by the resident or their legal representative. Additionally, the policy mandates that quarterly statements be provided to residents or their legal representatives. However, the POA did not receive these statements and was not informed about the closure of the IBT account. The facility's Director of Revenue and Finance (DRF) acknowledged the oversight but was unsure why the entire amount was withdrawn instead of just the excess over $4,500. The facility also failed to pay the resident's monthly care costs to the Managed Care Organization (MCO), resulting in an overdue amount exceeding $10,000. The DRF indicated that the funds from the IBT account were transferred to the resident's trust account to cover these overdue costs. The POA was aware of the overdue payments but had instructed the MCO to contact the facility, as it was the representative payee. The lack of communication and proper financial management by the facility led to the deficiency in safeguarding the resident's financial affairs.
Failure to Conduct Thorough Background Checks for Staff
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not conducting thorough background checks for two Business Office Managers (BOM-G and BOM-H) out of seven staff reviewed. According to the facility's policy dated 7/15/22, potential employees must be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, which includes conducting background, reference, and credentials checks. However, upon review on 2/20/25, it was found that BOM-G, hired on 8/10/23, did not have a Department of Justice (DOJ) letter, and BOM-H, hired on 10/20/23, lacked both DOJ and Integrated Background Information System (IBIS) letters. The Nursing Home Administrator (NHA-A) confirmed the absence of these documents, which are expected to be obtained for all staff before their first day of work.
Failure to Complete Neuro Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neuro checks were completed post-fall in accordance with its policy for three residents who experienced unwitnessed falls. The facility's policy required neuro checks to be conducted initially, then every hour for three hours, every four hours for six checks, and every eight hours for six checks, with any abnormal findings reported to the Medical Doctor immediately. However, the surveyor found that neuro checks were not completed as required for residents R2, R4, and R1, leading to a deficiency in the facility's fall prevention and management practices. Resident R2, who had a history of mild cognitive impairment and was at risk for falls, experienced multiple unwitnessed falls. The surveyor noted several instances where neuro checks were either missing or not completed in a timely manner according to the facility's policy. For example, after a fall on 11/10/24, the first neuro check was not documented until the following day, and several other falls also had missing or delayed neuro checks. Similarly, Resident R4, who was severely cognitively impaired and at risk for falls, had unwitnessed falls with incomplete neuro checks. For instance, after a fall on 1/18/25, the first neuro check was not completed until two days later. Resident R1, who had intact cognition but was at risk for falls, also had unwitnessed falls with missing neuro checks. The surveyor's interviews with staff revealed that neuro checks were not always completed, and there was confusion among staff about the timing and completion of these checks, particularly with agency staff.
Failure to Conduct Comprehensive Background Checks for CNA
Penalty
Summary
The facility failed to implement its abuse policy by not conducting comprehensive background checks for a Certified Nursing Assistant (CNA-C) who was hired on February 27, 2024. The facility's policy, revised on July 15, 2022, mandates that potential employees be screened for any history of abuse, neglect, exploitation, or misappropriation of resident property, including conducting background checks consistent with state laws and regulations. However, the background check for CNA-C did not include out-of-state criminal or caregiver background checks, despite CNA-C having lived in two other states within the last three years. During a survey conducted on November 11, 2024, the surveyor reviewed CNA-C's background check information and noted the absence of out-of-state checks. Upon inquiry, the Nursing Home Administrator (NHA-A) confirmed that the facility had not completed these checks for CNA-C and had no additional information to provide. Although an audit and process improvement plan were conducted to ensure employee files were complete, the out-of-state background checks for CNA-C remained missing as of October 31, 2024.
Failure to Complete PASRR Level II Screens for Residents
Penalty
Summary
The facility failed to ensure that PASRR (Pre-Admission Screening and Resident Review) requirements were met for five residents, leading to deficiencies in the assessment and care planning for individuals with mental disorders or intellectual disabilities. The PASRR process involves a Level I Screen to identify potential mental illness (MI) or intellectual disability (ID), followed by a Level II Screen for those who test positive, to determine the need for specialized services. However, the facility did not complete the necessary Level II Screens for residents who remained in the facility beyond the initial 30-day county exemption period. Resident 9 was admitted with diagnoses including epilepsy, unspecified intellectual disabilities, anxiety disorder, and depression, and was prescribed psychotropic medication. Despite these indicators, the PASRR Level I Screen incorrectly marked no for major mental disorder and no for signs and symptoms of MI, and the facility failed to complete a Level II Screen after the 30-day exemption expired. Similarly, Resident 22, with a history of ID and MI, was admitted with a Level I Screen that inaccurately marked no for major mental disorder and psychotropic medication, and no Level II Screen was conducted after the exemption period. Other residents, such as Resident 15, who had a serious mental illness and was on multiple psychotropic medications, did not receive a Level II Screen despite the Level I Screen indicating the need for one. Resident 57's Level I Screen was completed incorrectly, failing to acknowledge a major mental disorder despite the resident receiving medication for such conditions. Lastly, Resident 43, with diagnoses including vascular dementia and PTSD, was not provided a Level II Screen despite the Level I Screen indicating the necessity. These oversights highlight a systemic issue in the facility's PASRR process, affecting the care and services provided to residents with mental health needs.
Failure to Provide Timely Assessment and Consistent Wound Care
Penalty
Summary
The facility failed to ensure appropriate care and treatment for a resident (R42) who experienced a significant change in condition. On 4/1/24, R42 reported feeling unusually chilled, but the facility did not complete an appropriate assessment or notify the physician in a timely manner. It was only after R42's condition worsened, showing symptoms such as a high temperature, elevated pulse, and respiratory issues, that the physician was notified, and R42 was sent to the emergency room. The delay in assessment and notification contributed to R42 being diagnosed with sepsis at the hospital. Additionally, the facility did not consistently provide wound care as ordered for R42. The treatment administration records (TARs) indicated multiple instances where wound care was not documented as completed on the scheduled dates. Specifically, wound care for R42's left lower leg and right heel was missed on several occasions in March, April, and May 2024. There was no documentation in R42's medical record explaining why the wound care was not completed on these dates. Interviews with staff revealed a lack of communication and proper procedure when R42 reported feeling chilled. Certified Nursing Assistants (CNAs) did not report the change in condition to the Licensed Practical Nurse (LPN) on duty, and the LPN did not notice any unusual symptoms during the shift. The Director of Nursing (DON) confirmed that staff should document reasons for missed wound care and that feeling chilled should prompt a temperature check and notification of the provider. The failure to follow these protocols resulted in inadequate care for R42.
Failure to Provide Routine Nail Care for Resident
Penalty
Summary
The facility failed to provide routine nail care for a resident, identified as R19, who was dependent on staff for all activities of daily living. R19 had a medical history including diabetes, encephalopathy, and stroke, and had severely impaired cognition. The facility's Nail Care Policy required regular nail care, especially for residents with conditions like diabetes. However, observations by the surveyor on two consecutive days revealed that R19's fingernails were approximately a half inch long with a brown substance underneath, indicating neglect in nail care. Interviews with facility staff, including a CNA, an LPN, and the Director of Nursing, confirmed that nail care was not performed as per the facility's policy. The CNA mentioned that nail care should be provided during weekly showers, and the LPN confirmed that nurses are responsible for nail care for diabetic residents. The Director of Nursing acknowledged that it appeared to have been a few weeks since R19's nails were last cared for, further verifying the deficiency in adhering to the facility's nail care policy.
Failure to Act on Pharmacy Recommendations for a Resident
Penalty
Summary
The facility failed to ensure that pharmacy recommendation reports were acted upon by a physician for a resident reviewed for unnecessary medications. The resident, who had diagnoses including cerebral palsy, epilepsy, and anxiety, was subject to monthly pharmacy reviews. On two occasions, dated 12/20/23 and 1/22/24, the consultant pharmacist made recommendations regarding the resident's medication regimen, specifically concerning the prescription of diazepam without a stop date. However, these recommendations were not reviewed or acted upon by a physician or nurse practitioner. The facility's policy required that recommendations from the consultant pharmacist be made available to the care team and acted upon within 30 days. Despite this, the surveyor found that the physician/prescriber response was not documented for the review dated 12/20/23, and there was no clinical pharmacy report or physician response for the review dated 1/22/24. The Nursing Home Administrator confirmed these findings, acknowledging that the recommendations were not addressed, and the necessary documentation was missing from the resident's medical record.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring of high-risk medications for two residents, leading to a deficiency in medication management. Resident 18 was prescribed divalproex sodium for epilepsy, but the plan of care did not include monitoring for adverse reactions or potential side effects, despite the resident being at risk for such effects. The Director of Nursing confirmed the absence of monitoring interventions in the resident's care plan, which is contrary to the facility's Medication Management Policy that requires monitoring for unnecessary drugs. Similarly, Resident 15 was prescribed insulin glargine for type 2 diabetes, but their plan of care also lacked monitoring for adverse reactions or potential side effects. The Director of Nursing verified the insulin order and acknowledged the omission of monitoring interventions in the care plan. This oversight in monitoring high-risk medications for both residents indicates a failure to adhere to the facility's policy, which emphasizes the evaluation of residents for adverse consequences of medications.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during the provision of care to a resident. The CNA did not perform hand hygiene after removing gloves on multiple occasions while providing incontinence care. This included handling soiled items and moving from contaminated to clean tasks without washing hands or using an antiseptic hand rub, contrary to the facility's Hand Hygiene policy. During the observation, the CNA was seen providing pericare, removing a stool-soiled dressing, and handling various items in the resident's environment without performing hand hygiene between glove changes. The Assistant Director of Nursing (ADON) confirmed that the CNA should have completed hand hygiene after removing soiled gloves and before donning clean ones. This lapse in protocol was observed during care for a resident who required assistance with incontinence and had a stool-soiled dressing on the right buttock.
Inadequate Reconciliation of Controlled Medications
Penalty
Summary
The facility did not ensure adequate reconciliation of controlled medications for all four units, potentially affecting 12 residents who were prescribed controlled medications. The nurse-to-nurse controlled substance count verification forms were not consistently filled out, as required by the facility's Medication Administration and Controlled Substances policy dated January 2023. This policy mandates that at each shift change, a physical inventory of controlled medications is conducted by two licensed clinicians and documented on an audit record. However, the surveyor observed multiple instances across all units where these forms were missing signatures, indicating that the required counts were not performed or documented properly. Specifically, the surveyor noted missing signatures on various dates and shifts for the 100, 200, 300, and 400 units. For example, on the 100 unit, signatures were missing for three consecutive shifts on March 25. Similar patterns of missing signatures were observed on the other units, with the 200 unit having the most frequent occurrences. During an interview, the Nursing Home Administrator confirmed that two nurses should count and sign the verification forms between each shift, verifying the deficiency in the facility's practice of controlled substance reconciliation.
Incomplete Investigation of Neglect and Medication Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a registered nurse (RN) and residents on the 300 wing. The incident occurred when staff observed the RN sleeping in their car during their shift and appearing to be under the influence of a substance. The RN refused a drug test and was subsequently terminated. During the investigation, it was discovered that the RN did not sign out morning medications for residents on the 300 wing on the day of the incident. However, the controlled drug logs showed that the RN had signed out scheduled and as-needed medications for one resident, but these were not documented as administered in the Medication Administration Record (MAR). The facility's investigation did not identify or rule out potential misappropriation of medication, as required by their policy on abuse, neglect, and exploitation. The Nursing Home Administrator (NHA) admitted that the controlled drug logs were reviewed during the investigation but was unaware that the RN had signed out controlled medications until informed by the surveyor. This oversight indicates that the facility did not conduct a thorough investigation to determine if misappropriation of medication had occurred. The failure to follow the facility's policy on investigating allegations of neglect and potential misappropriation of medication resulted in an incomplete investigation and a deficiency in ensuring resident safety and proper medication administration.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility did not have a qualified Social Worker, which had the potential to affect all 69 residents residing in the facility. The Social Services Director (SSD) and Social Services Coordinator (SSC) did not have degrees in social work or a related human services field and did not have one year of supervised social work experience in a health care setting. The Facility Assessment indicated the facility is licensed for 125 beds with an average daily census between 50-65 residents over the last 6 months and stated the facility provides a social worker, mental health social worker/counseling services to its residents. The SSD was hired on 2/14/24 as a full-time employee with a degree in Health Care Administration and previous work experience in behavioral intervention and working with adolescents with autism. The SSD confirmed they were not certified as a Social Worker in the State of Wisconsin and did not have one year of supervised social work experience in a health care setting. The SSC was hired in August of 2023 as a Certified Nursing Assistant (CNA) and started in the Social Services Department in December of 2023 while pursuing a biomedical degree. The SSC confirmed they were not certified as a Social Worker in the State of Wisconsin, did not have a degree in social work or human services, and did not have one year of supervised social work experience in a health care setting. The Nursing Home Administrator confirmed the facility's previous Social Worker left in January of 2024 and was certified with the State of Wisconsin.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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