Greendale Park Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Greendale, Wisconsin.
- Location
- 5404 W Loomis Rd, Greendale, Wisconsin 53129
- CMS Provider Number
- 525549
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Greendale Park Nursing And Rehab during CMS and state inspections, most recent first.
An incident of physical abuse between two residents was not reported to the state survey agency within the required two-hour timeframe. An LPN witnessed the altercation and notified the DON, who then contacted the ADM. Due to misunderstanding of the reporting policy, the ADM submitted the report the next day instead of immediately as required.
The facility did not complete a thorough investigation into an incident of resident-to-resident abuse, failing to interview or document statements from witnesses, including two residents and staff who observed the event. Despite policy requirements to interview all involved and maintain complete records, key witness accounts were missing from the investigation documentation.
A required discharge MDS assessment was not completed or transmitted for a resident who was transferred to the hospital and did not return. Review of the electronic health record and staff interviews confirmed the omission, with the MDS coordinator unable to provide a reason for the oversight. Both the DON and NHA were notified of the missing assessment.
A resident with a G-tube did not receive enteral feeding according to physician orders, as the feeding continued during scheduled off times and staff were unclear about the feeding schedule. Additionally, there were no documented interventions or orders for monitoring or caring for the G-tube site, despite facility policy requiring such care. The resident, who was nonverbal and dependent on staff, was observed with leaking tube feeding and lacked appropriate site monitoring and documentation.
A resident was transferred or discharged without adequate preparation to ensure their needs and preferences were met, resulting in a failure to provide a safe and individualized transition.
Two residents were transferred to the hospital on multiple occasions without receiving the required written transfer and bed-hold notices, which should have included details such as the reason for transfer, bed-hold duration, appeal rights, and ombudsman contact information. Review of records and staff interviews revealed that the facility did not consistently provide or document these notices, and staff were unclear about who was responsible for this process.
Two residents with significant cognitive and physical impairments did not have comprehensive, person-centered care plans addressing urinary incontinence, including measurable objectives and timeframes. Although staff reported providing incontinence care every two hours or as needed, this frequency was not documented in the care plans or CNA Kardex, and documentation of care provided was inconsistent. Nursing staff and management acknowledged that care plans lacked specific instructions, resulting in a deficiency in meeting regulatory and facility policy requirements.
A medication error rate above 5% was identified when an LPN failed to prime both Humalog and Glargine insulin pens before administration and did not date the Glargine pen upon opening, as observed during a medication pass for a resident. Interviews confirmed that facility policy requires priming and dating of insulin pens, but the LPN was unaware of the correct procedure.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with multiple comorbidities and incontinence was admitted with several stage 2 pressure injuries and MASD. The facility failed to conduct timely skin assessments and did not implement appropriate wound treatments upon admission and readmission. No treatment was provided for several days, resulting in the development and worsening of a stage 3 pressure injury that required surgical debridement. An incontinence care plan was not implemented, and appropriate wound care was delayed until the resident was seen by a wound physician.
A resident with a history of diverticulosis and constipation did not receive appropriate bowel monitoring or interventions upon admission, despite being at risk due to medical history and opioid use. Documentation of bowel elimination was inconsistent, and staff failed to assess or address the resident's complaints of nausea and diarrhea. After a hospital visit revealed significant stool burden, recommended medication changes were not implemented, and a care plan for constipation risk was not initiated. Staff interviews revealed gaps in communication and documentation, and the facility could not provide a bowel monitoring policy when requested.
A resident with severe cognitive impairment, total incontinence, and existing pressure injuries did not have an individualized incontinence care plan implemented, despite facility policy and clinical indications. The care plan and Kardex lacked specific interventions such as a check and change schedule, and staff interviews confirmed the absence of documented incontinence management, contributing to ongoing skin complications.
A resident at high risk for pressure injuries did not receive adequate care upon admission, leading to a facility-acquired pressure injury. The facility failed to conduct a comprehensive skin assessment and delayed implementing treatment orders. Inaccurate wound assessments and missed treatments further compromised the resident's care, despite interventions like heel boots and an air mattress.
A resident with multiple health issues experienced a fall from bed, found with an arm stuck in a bed rail, due to inadequate supervision and lack of a prior bed rail assessment. The facility failed to conduct a thorough investigation or reassess the appropriateness of the bed rails, leading to discrepancies in staff accounts and insufficient updates to the resident's care plan.
A resident with mobility impairments and cognitive intactness was found with bed rails installed without a prior risk assessment, contrary to facility policy. The resident's arm became entrapped in the bed rail, requiring emergency services. Staff interviews revealed that therapy assessments were not completed before bed rail installation, and the facility administration acknowledged the oversight without providing further information.
The facility's assessment was found lacking essential details on water management, infection prevention, and infectious disease management, potentially affecting all 76 residents. The DON acknowledged the omission during a surveyor's review and provided an updated assessment after being informed of the necessary components.
The facility failed to ensure RN coverage for at least eight consecutive hours daily on 17 days and did not designate a charge nurse for each shift. Staffing schedules lacked clarity on RN and agency staff roles, and the omission of charge nurse assignments was acknowledged as an error. Despite efforts to hire RNs and use agency staff, the facility struggled to maintain required coverage.
The facility failed to maintain an effective infection prevention and control program, with an outdated Water Management Plan lacking current standards and testing for Legionella. A resident's medication was handled barehanded by a nurse, breaching infection control practices. The facility's infection surveillance was inaccurate, missing a COVID-19 case, and the facility assessment lacked infection prevention information. Staff interviews revealed a lack of awareness and proper implementation of infection control measures.
The facility did not ensure that five CNAs completed the required annual 12 hours of educational training. CNA-C completed only 8 hours, and CNA-D completed only 7 hours in the last 12 months. This deficiency was identified through a record review and staff interview, with no explanation provided for the incomplete training.
A resident's medical record lacked a signed advance directive form for CPR, despite facility policy requiring this upon admission. The resident, with multiple health issues, had no care plan for advance directives, and the form was only completed after a surveyor's request. Interviews revealed the guardian had not signed the form, and there was no documentation of discussions about advance directives.
A facility failed to provide appropriate dialysis care for a resident, lacking physician orders, assessments, and a care plan for dialysis. The resident, with complex medical needs, did not have coordinated care with the dialysis center, and the facility's DON was initially unable to provide necessary information. The care plan was only updated after surveyor inquiry, indicating a deficiency in managing the resident's dialysis needs.
The facility failed to properly assess and obtain informed consent for bed rail use for two residents, with assessments not updated and consent not documented. Additionally, there was no routine maintenance schedule for bed rails, contrary to facility policy. These deficiencies were noted during surveyor interviews and observations.
The governing body of a facility failed to implement effective financial management policies, resulting in significant arrears with multiple vendors. This included essential services like pharmacy, food distribution, and medical equipment, threatening service disruptions. Interviews revealed a lack of awareness among staff about the financial issues, with responsibilities deferred to external consultants. The facility's financial instability could impact the care and safety of all residents.
A facility failed to prevent abuse by not implementing proper screening procedures for a CNA, who was later involved in an allegation of sexual assault against a resident. The CNA inaccurately completed a BID form, and the facility did not verify the DOJ background check or obtain references. This allowed the CNA to care for a resident who alleged sexual abuse, creating immediate jeopardy.
A resident did not receive a CBC and BMP as ordered due to a break in lab service from unpaid bills, which was not documented. The resident experienced multiple episodes of diarrhea, but the facility failed to assess the condition or obtain a stool sample to rule out infection. The resident was later diagnosed with dehydration, C-Diff, and a UTI at the hospital. The facility did not follow its incontinence policy, leading to a deficiency in care.
The facility failed to provide adequate pressure ulcer care and prevention for two residents at high risk for pressure injuries. One resident developed a stage 3 pressure injury and a DTI, while another developed a DTI, with care plans not revised to include necessary interventions. Initial assessments and treatments were delayed, and documentation was lacking, leading to deficiencies identified by surveyors.
The facility failed to provide required annual QAPI training to 4 out of 5 CNAs, as per their policy. The DON acknowledged a change in training software, which led to the inability to verify training completion. Only one CNA had completed the QAPI training, while the facility could not provide documentation for the others, potentially affecting all 69 residents.
A resident self-administered Entresto for heart failure without a proper assessment, physician's order, or care plan in place. The facility's policy requires an interdisciplinary team assessment and documentation for self-administration, which was not completed. The issue was identified, and the facility began administering the medication to the resident.
A resident's right to privacy was breached when their package was opened by an LPN without permission. The LPN was instructed by a receptionist to open the package, suspecting it contained knives, but it was actually medication. The facility's policy states that residents' mail should not be opened by staff, yet this incident occurred, leading to the resident's upset.
The facility failed to promptly investigate and resolve grievances for three residents during a survey. Despite having a grievance policy, the facility did not document or investigate grievances until prompted by the surveyor. Concerns about staff behavior and call light responses were not addressed, and documentation was incomplete, resulting in unresolved grievances.
The facility failed to report two incidents of alleged abuse involving residents to the State survey agency within the required timeframe. An allegation of sexual assault was not reported immediately, and a physical abuse allegation was reported two days late. The facility's policy requires timely reporting, but these incidents were not reported as mandated.
The facility failed to thoroughly investigate allegations of abuse, misappropriation, and neglect involving three residents. A resident with cognitive impairment reported a sexual assault, but not all staff on duty were interviewed. Another resident reported missing money and inappropriate behavior by a CNA, but the investigation lacked interviews with all relevant staff. A third resident alleged neglect, but staff were not questioned about their knowledge of the incident.
A resident did not receive documented showers over a month-long period, despite requiring substantial assistance for bathing. The facility's new system for tracking showers failed to ensure the resident's hygiene needs were met, as confirmed by staff interviews and lack of documentation.
A resident with hemiplegia and bilateral above-knee amputation did not receive adequate supervision and fall prevention interventions as outlined in their care plan. Despite the plan's directives, observations revealed the absence of a body pillow on the bed's right side and the call light not consistently within reach. The LPN confirmed these measures should have been in place, but no explanation was provided for the oversight.
A resident with Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Sleep Apnea did not receive appropriate respiratory care as the facility failed to document MD orders for CPAP settings and cleaning, and did not include CPAP use in the care plan. The LPN Unit Manager confirmed the need for such documentation, which was missing, and the issue was noted during a surveyor's investigation.
Two residents in the facility experienced significant medication errors due to unavailable medications. One resident, with a kidney transplant, missed six doses of Tacrolimus, while another, with heart failure, missed nine doses of Ivabradine. The facility's process for handling unavailable medications was inadequate, lacking clear policies on notifying providers and missing necessary medications in the contingency supply.
A resident with diabetes and bilateral above-knee amputations had inaccurate medical records indicating daily diabetic foot checks were performed, despite the absence of feet. The facility's MAR inaccurately documented these checks as completed, which was confirmed through a surveyor's review and staff interviews.
A resident with significant medical conditions complained of chest and rib pain. A Med Tech administered Tylenol but failed to alert a nurse, obtain vital signs, or determine pain level. The Med Tech did not follow up to verify medication effectiveness or notify the physician, contrary to facility policy.
A resident on Warfarin was not adequately monitored for side effects due to the lack of a specific care plan and monitoring orders. The facility's policy on managing anticoagulant therapy was not followed, leading to a deficiency identified by the surveyor.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to the state survey agency within the required two-hour timeframe. According to facility policy, all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, an altercation occurred in which one resident hit another on the shoulder after being run into by a power wheelchair. The incident was witnessed by an LPN, who notified the Director of Nursing (DON) shortly after the event. The DON then contacted the Administrator (ADM), who was responsible for reporting abuse allegations to the state survey agency. Despite the policy requirements, the ADM submitted the abuse report to the state survey agency the following day, well beyond the two-hour window. Interviews revealed that both the DON and ADM were unclear about the correct reporting timeframe, with the DON believing the report was due within 24 hours and the ADM unaware that all abuse allegations required reporting within two hours, regardless of injury severity. Both residents involved had intact cognition and no behavioral symptoms documented during recent assessments.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident abuse involving two residents. According to facility policy, all involved persons, including witnesses, should be identified and interviewed, and complete documentation of the investigation should be maintained. However, the investigation did not include interviews or documentation from key witnesses who were present during the incident, such as two other residents and staff members who observed the altercation. The incident in question involved one resident hitting another on the shoulder, followed by a physical response. Both residents involved had intact cognition as indicated by their BIMS scores, and neither exhibited behavioral symptoms during their respective assessment periods. The event was reported promptly to the state survey agency, and staff separated the residents at the time of the incident. Despite this, the facility's investigative documents lacked statements or interviews from the witnesses who were present, including two residents with intact cognition and staff who directly observed the event. Interviews with facility staff revealed that the social services director and the director of nursing were unaware that other residents had witnessed the incident, and there was no documentation of interviews with the staff members who responded to the event. The administrator confirmed that all present during the incident should have been interviewed, but the investigation records did not reflect this. As a result, the facility did not meet its own policy requirements for a complete and thorough investigation of the abuse allegation.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a required discharge Minimum Data Set (MDS) assessment for one of two residents reviewed for MDS assessments and transmission. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records, including discharge assessments, to the Centers for Medicare and Medicaid Services' (CMS) Internet Quality Improvement Evaluation System (iQIES). The discharge assessment is to be completed no later than 14 calendar days after the discharge date. In this case, a resident was admitted to the facility and later transferred to the hospital, not returning to the facility. Upon review of the electronic health record, it was found that no discharge MDS assessment was completed or transmitted after the resident's discharge. During interviews, the MDS coordinator confirmed that a discharge MDS assessment is typically completed within seven days of a resident's discharge, but acknowledged that no such assessment was completed for this resident and was unsure why it was missed. The deficiency was confirmed through record review and staff interviews, with both the Director of Nursing and the Nursing Home Administrator being informed of the missing discharge MDS assessment. No additional information or explanation for the omission was provided by facility staff.
Failure to Follow G-Tube Feeding Orders and Provide Site Care
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube (G-tube) did not receive care and services in accordance with physician orders and facility policy. The resident had an order for enteral feeding with Jevity 1.5 at 65 mL/hour for 20 hours, to be stopped at 10:00 AM and restarted at 2:00 PM. However, multiple observations by the surveyor showed that the tube feeding continued to run during the period it was supposed to be off. Staff members, including CNAs and an LPN, were unclear about the feeding schedule, with some believing the feeding was continuous. The feeding was also observed to be leaking, resulting in formula on the resident's bed sheet. Further review revealed that there were no physician orders or documented interventions for monitoring, treatment, or care of the resident's G-tube site. The facility's policy required daily assessment and care of the G-tube site, including cleaning, monitoring for infection, and documentation of care provided. Interviews with staff, including the LPN, unit manager, and DON, confirmed that there were no orders or documentation for G-tube site monitoring or care on the resident's MAR/TAR or care plan. Staff were unsure about the expectations for G-tube care and could not locate relevant information in the resident's records. The resident in question had significant medical needs, including anoxic brain damage, chronic respiratory failure, protein-calorie malnutrition, and was dependent on staff for all activities of daily living. The resident was nonverbal, unable to follow commands, and at high risk for malnutrition. Despite these vulnerabilities, the facility failed to ensure that the resident's G-tube feeding was administered as ordered and that appropriate monitoring and care of the G-tube site were provided and documented.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation that indicated the resident's individual requirements and choices were not fully considered or addressed during the transfer/discharge planning process. As a result, the resident was not properly prepared for a safe transition, and the necessary steps to ensure their needs and preferences were met were not completed.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written transfer and bed-hold notices to two out of three residents reviewed who were hospitalized. Specifically, the facility did not issue documentation to the residents or their representatives that included the date and reason for transfer, location of transfer, duration of bed-hold, appeal rights, and contact information for the State Long-Term Care Ombudsman. This omission was identified through interviews and record reviews, which revealed that no such notices were found in the electronic health records (EHR) for the residents in question. One resident with diagnoses including muscle wasting, acute and chronic respiratory failure, and a tracheostomy was transferred to the hospital on three separate occasions. Progress notes documented the clinical events leading to each transfer, such as labored breathing, trach removal, and sepsis, but there was no evidence that the required transfer and bed-hold notices were provided or documented in the EHR. Another resident with multiple chronic conditions and an activated healthcare power of attorney was also transferred to the hospital, and again, no written notice was found in the EHR for this event. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for issuing transfer and bed-hold notices. The Nursing Home Administrator, Social Services Director, Admissions Director, RN Unit Manager, and Health Unit Coordinator each gave differing accounts of who was responsible for providing and documenting these notices. Some staff believed the notice was only required at admission or monthly, rather than at each transfer, and others were unaware of the requirement altogether. This lack of consistent process and documentation led to the deficiency.
Failure to Develop Comprehensive Incontinence Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address the urinary incontinence needs of two residents. For one resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living, the care plan lacked specific instructions regarding the frequency of incontinence care. Although staff interviews indicated that incontinence care was generally provided every two hours or as needed, this frequency was not documented in the resident's care plan or on the CNA Kardex. Additionally, documentation of incontinence care provided was inconsistent, with significant gaps in the electronic health record regarding the number and timing of urinations. For another resident with a history of stroke, diabetes, chronic respiratory failure, and moderate cognitive impairment, the care plan also failed to include a person-centered approach to incontinence care. The resident was assessed as always incontinent of urine and bowel and dependent on staff for all care. While the CNA Kardex and staff interviews indicated that incontinence care was provided every two hours or as needed, there was no specific care plan developed to address the resident's incontinence needs, nor was the frequency of care documented in the care plan or Kardex. Interviews with nursing staff and management confirmed that the facility's practice was to provide frequent check and change for incontinent residents, but this was not consistently reflected in the care plans. The lack of measurable objectives and timeframes in the care plans for both residents did not meet the facility's own policy requirements or regulatory expectations for comprehensive, person-centered care planning.
Medication Error Rate Exceeds 5% Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with a calculated error rate of 5.88% based on 2 errors in 34 observed opportunities. During medication administration, a Licensed Practical Nurse (LPN) did not prime a resident's Humalog insulin pen prior to dialing the prescribed dose, contrary to facility policy and procedure. The same LPN also failed to prime the resident's Glargine insulin pen before administration and did not ensure the insulin pen was dated when opened, as required for tracking expiration. These actions were directly observed by the surveyor during the medication pass. Interviews with the LPN and the Unit Manager confirmed that insulin pens should be primed with 2 units before each use and dated upon opening, with the Unit Manager stating that insulin expires 28 days after being opened. The LPN demonstrated a lack of knowledge regarding the priming procedure, stating incorrectly that priming was not necessary. The surveyor verified these deficiencies through direct observation, interviews, and review of facility policy, resulting in the identification of two medication errors for the resident.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple pressure injuries did not receive timely and appropriate assessment and treatment upon admission and readmission. The facility's own policies required a comprehensive skin assessment by a licensed or registered nurse upon admission and weekly thereafter, as well as prompt implementation of evidence-based wound treatments in accordance with physician orders. However, after the resident was admitted with several stage 2 pressure injuries and moisture-associated skin damage (MASD), no treatment was implemented for five days until the wound physician evaluated the resident. During this period, the resident developed a stage 3 pressure injury on the coccyx, which required surgical debridement. Upon the resident's readmission following hospitalization, the facility again failed to conduct a comprehensive assessment and did not implement appropriate treatments for the existing pressure injuries. The clinical admission note indicated that skin issues had not been evaluated, and the documentation and measurements were unchanged from the previous admission, despite the presence of a stage 3 pressure injury. Only a barrier cream was applied two days after readmission, which was not an appropriate treatment for a stage 3 pressure injury. It was not until five days after readmission, when the wound physician evaluated the resident, that the stage 3 pressure injury was found to have worsened and required further debridement. Throughout this period, the resident, who had significant medical comorbidities including severe hypoxic ischemic encephalopathy, chronic respiratory failure, and incontinence, did not have an incontinence care plan implemented. The lack of timely assessment, failure to initiate appropriate wound care, and absence of an incontinence care plan contributed to the progression and exacerbation of the resident's pressure injuries, as documented by both facility records and wound care specialists.
Failure to Provide Bowel Monitoring and Timely Interventions for Resident at Risk of Constipation
Penalty
Summary
A resident with a history of diverticulosis, constipation, and other significant medical conditions was admitted to the facility and did not have a care plan initiated for bowel monitoring or interventions, despite being at risk due to their medical history and opioid use. There was no documentation of bowel elimination until several days after admission, and the first recorded bowel movement was diarrhea, accompanied by complaints of nausea. The resident was not assessed or monitored for these symptoms, and there was no documentation regarding the nausea and diarrhea. Additionally, bowel elimination was not consistently documented every shift, and staff interviews revealed inconsistent practices and lack of communication regarding the resident's symptoms. The resident was later transferred to the hospital for evaluation of nausea and abdominal cramping, where a CT scan revealed moderate colonic stool burden and a mildly distended rectal vault, correlating with constipation. Upon readmission to the facility, hospital recommendations to increase laxative use and add MiraLAX were not implemented, and a care plan for constipation risk and bowel monitoring was still not initiated. Physician orders from the hospital were not promptly addressed, and staff interviews indicated a lack of awareness and follow-through regarding the resident's bowel status and related symptoms. Throughout the resident's stay, there was a lack of comprehensive assessment and documentation when the resident experienced gastrointestinal symptoms, such as nausea and diarrhea. Staff failed to consistently monitor, document, and communicate the resident's bowel status and related complaints, and did not implement or update care plans or interventions as required by professional standards of practice and the resident's needs. The facility also could not provide a bowel monitoring policy when requested by the surveyor.
Failure to Implement Incontinence Care Plan for Resident with Pressure Injuries
Penalty
Summary
A deficiency was identified when a resident who was always incontinent of bowel and bladder, and admitted with pressure injuries and Moisture Associated Skin Damage (MASD), did not have an individualized care plan implemented to manage incontinence. The facility's own policy required staff to assess, document, and manage incontinence, including the use of a check and change strategy to protect skin integrity, but this was not reflected in the resident's care plan or Kardex. The resident's records indicated total dependence for toileting hygiene and bed mobility, and the presence of a stage 3 pressure injury and MASD, yet there was no documentation specifying the frequency of incontinence checks or changes. Surveyor interviews with facility staff, including the Nurse Practitioner and the Acting Director of Nursing, confirmed that while the need for moisture management and skin care was communicated, there was no evidence of a specific incontinence care plan or schedule being implemented. The Nurse Practitioner noted that the MASD was likely due to a combination of incontinence-related wetness and shearing, and emphasized the importance of routine checking and changing. However, neither the care plan nor the Kardex included these interventions, and staff were unable to provide additional documentation or clarification during the survey. The lack of a personalized incontinence management plan for the resident, who was at high risk for skin breakdown and had existing pressure injuries, was directly observed and confirmed through record review and staff interviews. This omission was cited as a failure to provide appropriate treatment and services to prevent further skin-related complications, as required by facility policy and regulatory standards.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for a resident, identified as R8, who was at risk for developing such injuries. Upon admission, R8's skin was not assessed, and an individualized care plan was not developed based on R8's risks and care needs. The facility also delayed implementing treatment orders for R8's pressure injuries, which were documented in the hospital discharge paperwork. The contracted wound care provider's assessments incorrectly identified the location of the wounds, and the facility's wound assessments were not comprehensive. R8 was admitted with diagnoses including muscle wasting, epilepsy, dysphagia, dementia, and peripheral vascular disease. The hospital discharge paperwork noted unstageable pressure injuries on R8's left great toe and right heel, but the facility did not place treatment orders until several days after admission. The facility's care plan for R8 included interventions for altered skin integrity and pressure injury prevention, but these were not effectively implemented. R8's Braden Scale assessments indicated a high risk for developing pressure injuries, yet the facility's assessments were inconsistent and did not accurately reflect R8's condition. The facility's failure to conduct a comprehensive skin assessment upon admission and the delay in implementing treatment orders contributed to the development of a new facility-acquired pressure injury on R8's right great toe. Additionally, the facility's skin assessments were not completed according to current standards of practice, lacking detailed characteristics and measurements of the wounds. The facility also missed wound care treatments on specific dates, further compromising R8's care. Despite the presence of heel boots and an air mattress, R8 was observed with heels resting directly on the bed, indicating inadequate pressure relief measures.
Inadequate Supervision and Bed Rail Assessment Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent falls for a resident, identified as R8, who was found on the floor with his left arm stuck in a bed rail. The incident occurred without a prior bed rail assessment, which is a necessary step before applying bed rails to a resident's bed. The facility did not conduct a thorough investigation to determine the root cause of the fall, nor did they reassess the appropriateness of the bed rails for R8. Additionally, the care plan was not updated in a timely manner to include interventions that could prevent future falls. R8, a resident with multiple diagnoses including muscle wasting, epilepsy, and dementia, was admitted to the facility and assessed as dependent on staff for mobility and transfers. Despite being cognitively intact, R8 experienced a fall from bed, which was not witnessed by staff. The facility's fall investigation revealed discrepancies in the documentation of the incident, such as the position in which R8 was found and the fact that his arm was stuck in the bed rail, which was not initially mentioned in the investigation report. Interviews with staff, including the Director of Therapy and a Licensed Practical Nurse, highlighted a lack of communication and awareness regarding the incident. The Director of Therapy was unaware of the incident involving the bed rail, and the LPN provided conflicting accounts of the event. The facility's failure to conduct a comprehensive investigation and reassessment of the bed rail use, along with the discrepancies in staff statements, contributed to the deficiency in providing a safe environment for R8.
Failure to Assess Bed Rail Risks Leads to Resident Entrapment
Penalty
Summary
The facility failed to assess the risk of entrapment and review the risks and benefits of bed rail use for a resident, leading to a deficiency. The resident, who is dependent on staff for mobility and has a history of muscle wasting, epilepsy, and dementia, was observed with bed rails on both sides of the bed without a completed side rail risk assessment. The facility's policy requires a person-centered approach and a comprehensive assessment before bed rails are used, including evaluating alternatives and obtaining informed consent, which was not followed in this case. The resident's medical record indicated that on a specific date, the resident's left arm became stuck in the bed rail, necessitating emergency medical services. Despite this incident, a bedrail/mattress safety assessment was only completed the following day, determining the resident was safe to have assist bed rails. Observations by the surveyor on subsequent days found the resident unattended with bed rails still in place, and the resident confirmed the recent incident of entrapment. Interviews with facility staff revealed that therapy is responsible for assessing bed rail needs, but the assessment was not completed before the bed rails were applied. The Director of Therapy confirmed that an assessment should be completed prior to bed rail installation. The surveyor notified the facility's administration of the concerns regarding the lack of assessment before the bed rails were used, but no additional information was provided by the facility leadership.
Facility Assessment Lacks Critical Information
Penalty
Summary
The facility failed to ensure that the Facility Assessment was updated to include critical information regarding the water management committee, the infection preventionist, and infectious disease management. This oversight has the potential to affect all 76 residents residing in the facility. On October 3, 2024, a surveyor reviewed the Facility Assessment and found that it lacked details on water management, the infection preventionist, and infectious disease management. During an interview on October 7, 2024, the Director of Nursing (DON) acknowledged that the recent update to the Facility Assessment accidentally omitted this information. The surveyor informed the DON of the necessary components that should be included in the Facility Assessment. Later that day, the DON provided an updated copy of the Facility Assessment after the surveyor requested the missing information. The surveyor also communicated these concerns to the Assistant Director of Nursing and the Assistant Nursing Home Administrator.
Deficiency in RN Coverage and Charge Nurse Designation
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, on 17 out of 152 days reviewed. This deficiency was identified through a review of the Payroll Based Journal (PBJ) report and staffing schedules, which showed that the facility did not meet the required RN coverage on specific dates. The Scheduler acknowledged the issue, citing challenges such as staff call-ins and difficulties in hiring RNs, despite attempts to fill gaps with agency staff. The Director of Nursing (DON) and Administrator were aware of the low RN hours and were actively trying to hire additional RNs, but the facility still lacked adequate RN coverage on the noted days. Additionally, the facility did not designate a charge nurse for each shift, as the staffing schedules did not indicate which nurse was assigned this role. The Scheduler admitted that the schedules should reflect the RN and agency staff, and that the omission of charge nurse assignments was an error. The DON stated that staff typically knew who was in charge, as they carried a phone to signify their role, but no additional information was provided to explain why the charge nurse was not identified on the schedule.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which has the potential to affect all 76 residents. The Water Management Plan (WMP) was outdated and did not reflect current standards of practice. It lacked the inclusion of the Infection Preventionist (IP) and did not have current water testing for Legionella, with the last test conducted in June 2023. The facility's surveillance of the infection control program was also inaccurate, as it failed to include a resident who tested positive for COVID-19 in September. During the survey, it was observed that a nurse handled a resident's medication with bare hands during preparation, which is a breach of infection control practices. The facility's policy on infection prevention and control, implemented in October 2022, was not adhered to, as evidenced by the lack of proper documentation and communication regarding the water management program and infection surveillance activities. The facility's assessment also lacked information on infection prevention and water management, which was acknowledged by the Director of Nursing as an accidental omission. Interviews with facility staff revealed a lack of awareness and proper implementation of the water management program. The Director of Maintenance admitted to not conducting necessary water testing for Legionella or other pathogens, and the Regional Director was unaware of the current water testing procedures. The Assistant Director of Nursing acknowledged the failure to accurately track and document COVID-19 cases, attributing it to a lack of communication and oversight. These deficiencies highlight significant gaps in the facility's infection prevention and control measures, posing a risk to resident safety.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) completed the required annual 12 hours of educational training. Specifically, CNA-C and CNA-D did not meet the training requirements, with CNA-C completing only 8 hours and CNA-D completing only 7 hours of training in the last 12 months. This deficiency was identified through a record review and staff interview conducted by the surveyor. The Nursing Home Administrator and Director of Nursing were informed of these findings, but no additional information was provided to explain why the facility did not ensure the completion of the required training hours.
Failure to Complete Advance Directive Forms for Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record contained signed advance directive election forms, specifically regarding Cardiopulmonary Resuscitation (CPR). The resident, who had multiple diagnoses including muscle wasting, atrial fibrillation, and dementia, was admitted without a completed advance directive form. The facility's policy requires that upon admission, the facility should determine if a resident has an advance directive and provide information about the right to refuse treatment. However, the resident's CPR consent form was not completed until the surveyor requested it, and there was no care plan for advance directives initiated. Interviews with facility staff revealed that the resident's guardian had not signed the form, and there was no documentation of discussions with the resident or guardian regarding advance directives. The Director of Nursing acknowledged that the code status should be included in the care plan, but it was not. The surveyor noted that the form was only completed after the issue was brought to the facility's attention, and there was still no physician order or care plan for the resident's advance directive in the electronic medical record.
Deficiency in Dialysis Care Coordination
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R426, who required such services. Upon admission, R426 did not have physician orders for hemodialysis or the frequency of dialysis sessions. Additionally, there were no assessments completed before or after dialysis sessions, and no care plan was in place to monitor and care for R426 in relation to dialysis and potential complications. The facility also lacked communication with the dialysis center for each visit, which is a critical component of coordinated care. R426 was admitted with multiple diagnoses, including sepsis, acute pyelonephritis, legionnaires' disease, dependence on renal dialysis, rhabdomyolysis, end-stage renal disease, and type 2 diabetes mellitus. Despite these complex medical needs, the facility's records did not reflect any physician orders or assessments related to dialysis sessions. The care plan for R426 was only updated after the surveyor's inquiry, indicating a lack of proactive management of the resident's dialysis needs. The Director of Nursing (DON) was unable to provide information regarding the resident's dialysis care when initially asked by the surveyor. It was later revealed that there was no communication between the facility and the dialysis center regarding R426's condition and treatment. The facility's policy required comprehensive care plans and coordination with the dialysis provider, which were not adhered to in this case. The lack of documentation and communication highlights a significant deficiency in the facility's management of dialysis care for R426.
Deficiencies in Bed Rail Assessment and Maintenance
Penalty
Summary
The facility failed to ensure proper assessment and informed consent for the use of bed rails for two residents, R7 and R66. R7's Bed Rail Assessment and Informed Consent for Use were not updated since early 2024, despite the presence of grab bars on both sides of the bed. The facility's policy requires these assessments to be reviewed quarterly, but this was not adhered to, as confirmed by the Director of Nursing (DON). R66 had a right grab bar attached to the bed frame, but there was no evidence that risks were explained or informed consent was obtained. The Bed Rail Assessment form for R66 was unsigned, and no informed consent was documented. Additionally, the facility did not enforce a routine maintenance and inspection schedule for bed rails. The Director of Maintenance confirmed that checks on bed canes were only performed when they were removed and reinstalled, with no scheduled inspections when the canes remained on the bed. This lack of regular maintenance and inspection was highlighted during the surveyor's interviews with facility staff. The facility's policy on the proper use of bed rails emphasizes a person-centered approach, requiring comprehensive assessments and informed consent before installation. However, the facility failed to comply with these guidelines, as evidenced by the lack of updated assessments and informed consent for R7 and R66, and the absence of a regular maintenance program for bed rails. These deficiencies were communicated to the facility's leadership during the surveyor's end-of-day meetings.
Governing Body's Financial Mismanagement Leads to Vendor Payment Delays
Penalty
Summary
The facility's governing body failed to establish and implement effective policies and procedures for managing and operating the facility, leading to significant financial mismanagement. This deficiency was identified during a survey where it was found that the facility's fiscal accounts were in arrears, affecting the payment to multiple vendors. The governing body did not ensure that contracted vendors were reimbursed and paid according to established contracts or invoiced amounts, which could potentially impact the care and treatment of all 75 residents in the facility. The survey revealed that the facility owed substantial amounts to various vendors, including those providing essential services such as waste management, pharmacy services, human resources consulting, electronic medical records, food distribution, and medical equipment. For instance, the facility owed over $1.2 million to AlixaRx for pharmacy services, with invoices outstanding for more than 151 days. Additionally, the facility had significant outstanding balances with Sysco Baraboo, a food distributor, and Point Click Care Technologies, which provides electronic medical records, both of which threatened service disruptions due to non-payment. Interviews with facility staff, including the Business Office Manager and the Nursing Home Administrator, indicated a lack of awareness or involvement in the financial issues, with responsibilities for payment and vendor management being deferred to external entities or consultants. The facility's financial instability was further highlighted by the outstanding balances owed to the Wisconsin Department of Health Services for bed tax fees and civil money penalties issued by CMS. The governing body's failure to ensure fiscal stability and oversight has the potential to affect the safety and care of all residents in the facility.
Failure to Prevent Abuse Due to Inadequate Screening
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, specifically in the case of a CNA who was involved in an allegation of sexual assault against a resident. The CNA inaccurately completed a Background Information Disclosure (BID) form by answering 'no' to a question about past criminal convictions, despite having a conviction for fourth-degree sexual assault. The facility did not verify the positive results of the Department of Justice (DOJ) background check against the BID form, nor did it obtain references for the CNA as part of the hiring process. This lack of thorough screening allowed the CNA to care for a resident who later alleged sexual assault. The resident involved in the allegation had a history of right and left above-knee amputation, hemiplegia and hemiparesis following cerebral infarction, anxiety disorder, and depression. The resident was assessed as cognitively intact in April but showed a decline to moderate cognitive impairment by June. The resident alleged that the CNA entered her room, touched her inappropriately, and forced her to touch him. Despite calling for help, no staff responded at the time of the incident. The resident reported the incident to a social worker the following morning, who then notified the Director of Nursing, the police, and the resident's Power of Attorney. The facility's failure to ensure the accuracy of the CNA's BID form and to conduct thorough background and reference checks allowed the CNA to provide care to a vulnerable resident, resulting in the resident alleging sexual abuse. This deficiency created a finding of immediate jeopardy, indicating a reasonable likelihood for serious harm. The facility's inaction in verifying the CNA's background and responding to the resident's calls for help contributed to the severity of the situation.
Failure to Provide Adequate Care and Monitoring for Resident with Diarrhea
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, identified as R6, did not receive a complete blood count (CBC) and basic metabolic panel (BMP) during the specified week as ordered by the physician. This lapse in care was attributed to a break in service from the lab due to unpaid bills by the facility, which was not documented or communicated effectively. Additionally, there was no documentation of the resident refusing the lab work, as claimed by the LPN/UM. R6 experienced multiple episodes of loose, watery diarrhea, which were documented by CNAs but not adequately assessed by the facility. Despite the documentation of 14 episodes of diarrhea, the facility did not obtain a stool sample to rule out an infectious process. The resident was eventually discharged to a family member and subsequently diagnosed with dehydration, C-Diff, and a urinary tract infection at the hospital. The delay in ordering Metamucil and the lack of a comprehensive assessment of the resident's bowel condition contributed to the deficiency. The facility's failure to monitor and report the resident's bowel status and obtain necessary lab work highlights a significant lapse in care. The APNP and nursing staff did not adequately communicate or document the resident's condition, leading to a lack of timely intervention. The facility's policy on incontinence was not followed, as appropriate treatment to prevent infections and restore continence was not provided. This deficiency underscores the need for improved communication, documentation, and adherence to care plans to ensure resident safety and well-being.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R4 and R5, who were at high risk for pressure injuries. R4, who was dependent on staff for bed mobility and had a high Braden Score indicating risk, developed a stage 3 pressure injury on her buttock and a Deep Tissue Injury (DTI) on her left heel. Despite these developments, the care plan was not revised to include necessary interventions such as offloading, turning, and repositioning. Initial assessments and measurements of the pressure injuries were not completed, and treatment was not immediately implemented. R5, who required maximal assistance for bed mobility, also developed a DTI on his right heel. Similar to R4, the facility did not implement care plan interventions for offloading, turning, and repositioning. There was no comprehensive assessment or measurements of R5's pressure injury, and documentation of the injury was lacking in the medical record. The facility's failure to document and assess the pressure injuries in a timely manner contributed to the deficiency. The facility's policy on pressure injury prevention was not followed, as evidenced by the lack of individualized interventions and documentation in the care plans for both residents. The facility's staff, including the wound care nurse, did not perform necessary assessments or implement physician-ordered treatments promptly. The facility's Director of Nursing acknowledged the issues with documentation and treatment, indicating that previous staff had not adhered to proper procedures, which led to the deficiencies identified by the surveyor.
Deficiency in QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that staff received the required annual Quality Assurance and Performance Improvement (QAPI) training, as evidenced by the lack of training documentation for 4 out of 5 Certified Nursing Assistants (CNAs) reviewed. The facility's policy mandates that training requirements be met annually and that the elements and goals of the facility's QAPI program be included in the training content. However, the surveyor found that the facility did not provide the necessary QAPI training to the majority of the CNAs reviewed, which could potentially affect all 69 residents in the facility. During the survey, the Director of Nursing (DON) acknowledged the issue, stating that a change in training software had occurred and that they did not have access to the previous system to verify training completion. Although the Nursing Home Administrator (NHA) later provided documentation confirming that other required trainings were completed, it was confirmed that only one CNA had completed the QAPI training. The facility was unable to provide documentation for the remaining four CNAs, indicating a deficiency in meeting the training requirements as per their policy.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident who was self-administering Entresto, a medication for heart failure, without proper assessment and authorization. The resident, who was admitted with a diagnosis of chronic heart failure, was documented as self-administering the medication from April 18, 2024, to May 3, 2024. However, there was no self-administration assessment completed, no physician's order for self-administration, and no care plan in place regarding the self-administration of medication. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medication, along with a prescriber's order and documentation in the care plan. Despite these requirements, the resident's medication administration record indicated unsupervised self-administration without the necessary assessments or orders. The issue was identified by the facility, and the resident's medications were subsequently administered by the facility starting May 3, 2024. The deficiency was brought to the attention of the facility's administration during a surveyor's exit meeting.
Resident's Mail Privacy Breach
Penalty
Summary
The facility failed to ensure a resident's right to privacy was maintained when receiving mail. A resident, identified as R7, who was cognitively intact, reported that their mail was delivered opened. The incident involved a package that was opened by an LPN without the resident's permission. The Director of Nursing (DON) confirmed that the package was opened by the LPN after being instructed by a receptionist to ensure the contents were safe. The LPN was told by the receptionist that the resident had been ordering knives, which prompted the opening of the package. However, the package contained medication, and the LPN had to explain to the resident why the package was opened. The receptionist, when interviewed, denied instructing staff to open residents' mail. Despite this, the DON maintained that the receptionist had instructed the LPN to open the package. The facility's policy on communication and mail handling, dated 3/26/2023, states that residents' rights to send and receive mail should be protected, and mail should not be opened by staff. The incident was brought to the attention of the Nursing Home Administrator and the DON, but no additional information was provided as to why the facility did not ensure the resident's right to privacy was maintained.
Failure to Promptly Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly investigate and resolve grievances for three residents, identified as R16, R17, and R18, during a survey. The facility's grievance policy mandates prompt resolution and communication with residents throughout the process, overseen by a designated Grievance Official. However, the surveyor found that grievances were not documented or investigated until prompted by the surveyor's inquiries. For R16, a grievance was noted during an abuse investigation, but the facility did not start investigating until after the surveyor's request, and the grievance remained unresolved. Similarly, R17's grievance was not addressed until the surveyor inquired about it. The resident had expressed concerns about a staff member's behavior and issues with call light responses. The facility's investigation summary did not address these specific concerns, and the grievance was not resolved. R18 also reported inappropriate behavior from a staff member during an abuse investigation, but the facility did not begin investigating until after the surveyor's inquiry, and the grievance remained unresolved. The surveyor noted that the facility's grievance process was not followed, as grievances were not promptly investigated or resolved, and documentation was incomplete. The facility's failure to adhere to its grievance policy resulted in unresolved grievances for the three residents, highlighting a deficiency in the facility's handling of resident concerns.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of alleged abuse involving residents R10 and R3 to the State survey agency and/or Nursing Home Administrator within the required timeframe. In the first incident, an allegation of sexual assault involving R10 was not reported to the Administrator and the State agency immediately, but rather several hours after the allegation was made. R10, who has moderate cognitive impairment, reported the incident to Social Services, who then informed the Director of Nursing. However, the report to the State agency was delayed until later in the day, well beyond the required two-hour window. In the second incident, an allegation of physical abuse involving R3 was not reported to the State Survey agency within the required two-hour timeframe. R3 reported being physically mishandled by staff, but the facility did not submit the necessary documentation to the State agency until two days after the incident was discovered. The Director of Nursing was unable to provide an explanation for the delay, as the employee responsible for submitting the report was no longer employed at the facility. The facility's policy mandates that all alleged violations be reported to the appropriate authorities within specified timeframes, particularly when the allegations involve abuse or result in serious bodily injury. Despite this policy, the facility failed to adhere to these requirements in both cases, resulting in a deficiency noted by the surveyors.
Incomplete Investigations into Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse, misappropriation of property, and mistreatment for three residents. Resident R10, who has a moderate cognitive impairment, reported a sexual assault by a staff member. The facility's investigation was incomplete as it only included interviews with two staff members present during the alleged incident, leaving out other staff who were on duty that night. The Director of Nursing could not explain why the investigation was not comprehensive. Resident R15, who is cognitively intact, reported missing money and an incident where a CNA did not assist with toileting and behaved inappropriately. The facility's investigation did not include interviews with all relevant staff, including those who might have been present when the money went missing or who could have witnessed the interaction with the CNA. The Nursing Home Administrator acknowledged the lack of thoroughness in the investigation. Resident R11 alleged neglect, stating that a CNA refused care and threw bedding at her. The facility's investigation included resident statements but failed to ask staff if they had any knowledge of the incident. The Director of Nursing, who was not in her role at the time, indicated that staff should have been questioned about their awareness of the situation. The facility did not provide additional information to explain the incomplete investigation.
Failure to Document and Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R7, received necessary assistance with activities of daily living, specifically in maintaining good grooming and personal hygiene. R7, who was cognitively intact and required substantial assistance for bathing, did not have any documented showers from mid-April to mid-May 2024. Despite R7's expressed importance of choosing between different types of baths, the facility's records and interviews revealed a lack of documentation and execution of scheduled showers for R7. Interviews with facility staff, including a CNA and LPN, indicated that a new system for tracking showers was implemented in March due to previous issues with missed showers. However, the system failed to ensure R7 received weekly showers as scheduled. The LPN and DON were unable to provide any documentation proving that R7 received showers during the specified period, highlighting a breakdown in the facility's process for ensuring residents' hygiene needs were met.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of fall prevention interventions for a resident identified as R10. R10 has a medical history that includes hemiplegia and hemiparesis following a cerebral infarction, hypertension, and bilateral above-knee amputation. The resident's care plan, initiated on February 15, 2024, included specific interventions to prevent falls, such as ensuring the call light and personal items were within reach, maintaining a well-lit and clutter-free environment, and placing a body pillow on the side of the bed closest to the door. However, during multiple observations on June 26 and June 27, 2024, the surveyor noted that the body pillow was not present on the right side of R10's bed, which was closest to the door, and the call light was not consistently within reach. Despite the care plan's directives, the surveyor observed R10 in bed without the body pillow on the right side during several checks, and the call light was found on the floor on one occasion. When questioned, R10 indicated that the staff only sometimes placed a pillow alongside her. The LPN/Unit Manager confirmed that the interventions should have been in place according to the care plan. The Nursing Home Administrator and Director of Nursing were informed of these observations, but no explanation was provided for the failure to implement the fall prevention measures as outlined in R10's care plan.
Deficiency in Respiratory Care for Resident Using CPAP
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as R7, who required the use of a CPAP machine. The deficiency was noted during an interview and record review, where it was found that R7 did not have medical doctor (MD) orders documenting the settings or cleaning schedule for the CPAP machine, as required by the facility's policy. Additionally, R7's care plan did not address the use of the CPAP machine, despite the resident's diagnoses of Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Sleep Apnea. The hospital discharge summary for R7 indicated the continuation of PAP therapy at bedtime, but this was not reflected in the facility's documentation. The surveyor's investigation revealed that the facility typically receives CPAP orders before a resident's arrival, and the machine is set up with the correct settings at that time. However, in R7's case, there was no documentation in the Medication Administration Record (MAR) regarding the use, cleaning, or maintenance of the CPAP machine. During an interview, the LPN Unit Manager confirmed that residents using CPAP machines should have corresponding orders and care plans, which were absent for R7. The issue was brought to the attention of the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing during the exit meeting, but no additional information was provided to explain the oversight.
Significant Medication Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that two residents, R8 and R9, were free from significant medication errors. R8, who had a kidney transplant, was prescribed Tacrolimus to prevent organ rejection. However, during the first five days of R8's admission, the resident missed six out of eleven doses due to the medication being unavailable. The facility's policy required staff to notify the pharmacy and the attending physician if medications were unavailable, but there was no specific policy on when to notify a provider after a resident missed medication. Interviews with staff revealed that the medication was not in the contingency supply, and there was a lack of documentation explaining the missed doses. R9, diagnosed with atrial fibrillation and heart failure, was prescribed Ivabradine. Between January 4 and January 9, 2024, R9 missed nine out of ten doses of the medication. Similar to R8's case, the medication was not available, and there was no documentation regarding the missed doses. Interviews with staff indicated that the facility had recently changed pharmacy providers due to previous issues with medication availability, but the new system had not yet resolved the problem for R9. The facility's Director of Nursing and Assistant Director of Nursing were unable to provide explanations for the missed doses for both residents. The surveyor noted that the facility's process for handling unavailable medications was inadequate, as there was no clear policy on notifying providers after missed doses, and the contingency supply did not include the necessary medications. The facility's failure to ensure the availability and administration of critical medications resulted in significant medication errors for both residents.
Inaccurate Medical Record Documentation for Resident with Amputations
Penalty
Summary
The facility failed to maintain accurate medical records for a resident identified as R10, who has a medical history of diabetes mellitus and bilateral above-knee amputations. Despite the resident's condition, the facility's records inaccurately documented that diabetic foot checks were being performed daily, as per a physician's order dated 4/4/24. This order required daily diabetic foot checks at bedtime, which were recorded as completed on the resident's medication administration records (MAR) for April, May, and June 2024. However, the resident does not have feet, making these documented checks impossible. The deficiency was identified during a surveyor's review of the resident's MAR and through interviews with facility staff. On 6/26/24, the surveyor observed the resident and confirmed the bilateral above-knee amputations. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) revealed that checks and initials on the MAR indicated that the treatment was performed. The DON acknowledged that the issue was supposed to have been corrected, yet the MAR continued to reflect the completion of diabetic foot checks as of June 25th, 2024.
Failure to Ensure Appropriate Treatment and Care
Penalty
Summary
The facility did not ensure that a resident received appropriate treatment and care according to orders, preferences, and goals. The resident, who had a history of significant medical conditions including COPD, diabetes, atrial fibrillation, and coronary artery disease, complained of pain across his chest and rib area. A Med Tech administered Tylenol but failed to alert a Registered Nurse to assess the resident's cardiac status, obtain vital signs, or determine the resident's pain level on a 0 to 10 scale. The Med Tech also did not follow up to verify the effectiveness of the medication and did not notify the attending physician of the resident's chest pain and potential change in condition. The facility's policy on Notification of Changes requires immediate communication of significant changes in a resident's condition to the resident, their representative, and the attending physician. Despite this policy, the Med Tech did not report the resident's chest pain to a nurse or ensure a follow-up assessment was conducted. The Med Tech documented the medication as effective without verifying this with the resident, and no Registered Nurse assessment or physician notification was made regarding the resident's chest pain. Interviews with facility staff, including the Med Tech, an Agency LPN, the attending physician, and the Director of Nursing, confirmed the lack of appropriate follow-up and communication. The Med Tech admitted to not considering the pain as chest pain and did not report it to a nurse. The attending physician stated that he would have wanted to be notified and would have expected a set of vital signs. The Director of Nursing acknowledged that the Med Tech should have reviewed the information with a nurse and that someone should have followed up with the resident and updated the physician if the pain was not effectively managed.
Failure to Monitor Warfarin Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs and adequately monitored for Warfarin side effects. The resident was admitted with an order for Warfarin, but the facility did not implement a care plan or orders to monitor for adverse side effects associated with anticoagulant therapy. The facility's policy on managing anticoagulant therapy was not followed, as there were no documented target symptoms, goals for use, or routine lab orders communicated to the physician in a timely manner. Additionally, the care plan did not include interventions to minimize the risk of adverse consequences, such as monitoring for bleeding and bruising, which are critical for residents on anticoagulant therapy. The surveyor's review of the resident's medical records revealed that the order to monitor for signs and symptoms of bleeding was vague and did not specify the source or location of the bleeding. Interviews with the MD and DON confirmed that staff should be monitoring for signs of side effects, including bleeding, bruising, changes in condition, and cardiac symptoms. Both the MD and DON acknowledged that there should have been specific orders and a care plan in place to guide staff in monitoring for these side effects. The lack of a comprehensive care plan and specific monitoring orders led to the deficiency identified by the surveyor.
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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