Hamilton Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Two Rivers, Wisconsin.
- Location
- 1 Hamilton Dr, Two Rivers, Wisconsin 54241
- CMS Provider Number
- 525664
- Inspections on file
- 28
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Hamilton Health Services during CMS and state inspections, most recent first.
A cognitively intact resident with multiple chronic conditions gave an agency LPN a small amount of cash for gas after the LPN stated they could not get home without money. Another nurse instructed the LPN to return the money, and the resident later confirmed to the ADON that the money had been given and returned, explaining they knew the LPN from a prior facility and believed their relationship made the gift acceptable. The ADON reported the incident to the NHA, but the NHA decided it was not an allegation of exploitation and did not report it to the State Agency, contrary to the facility’s abuse, neglect, and exploitation reporting policy.
A resident with multiple chronic conditions and intact cognition reported giving an agency LPN a small amount of cash for gas after the LPN stated they could not get home, and the money was later returned. The facility’s policy requires immediate, comprehensive investigation of alleged abuse, neglect, or exploitation, including interviewing all involved persons and potential witnesses. However, after confirming the exchange of money with the resident, the ADON did not pursue further investigation, and the NHA determined it was not an exploitation allegation and did not interview other residents or staff to identify any similar concerns, resulting in a failure to conduct a thorough investigation as required by facility policy.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with a tracheostomy did not have their care documented, while another was incorrectly recorded as receiving Hospice services. A resident prescribed antiplatelet medication was documented as receiving anticoagulant medication, and a PASRR Level II Screen was not reflected. Additionally, a resident's fall and prescribed medications were not accurately recorded. These issues were confirmed by the facility's RN responsible for MDS assessments.
The facility failed to ensure physician acknowledgment of pharmacy recommendations for four residents, leading to deficiencies in medication management. Several pharmacy recommendations, including dose reductions and medication monitoring, were not followed up or documented. The facility lacked a process for regular pharmacy reviews and physician follow-up, contributing to these deficiencies.
The facility failed to provide necessary Medicare coverage notices to two residents when their Part A benefits ended. One resident did not receive an Advanced Beneficiary Notice (ABN) form, and another did not receive a Notice of Medicare Non-Coverage (NOMNC) form, despite the termination of benefits being facility-initiated. These deficiencies were confirmed through staff interviews and record reviews.
A facility did not complete a Significant Change MDS assessment for a resident discharged from Hospice services. The resident, initially admitted with diffuse large B-cell lymphoma and receiving palliative care, was discharged from Hospice, but only Quarterly MDS assessments were completed afterward. The RN responsible for MDS assessments and the NHA confirmed that a Significant Change MDS assessment was required.
A resident experienced a severe weight gain of 38.93% over several months, and the facility failed to notify the physician and follow weight monitoring protocols. Despite the resident's diagnoses and medications affecting appetite, no new nutritional interventions were documented, leading to a deficiency finding.
A facility failed to monitor a resident for adverse reactions to lamotrigine, prescribed for bipolar disorder. The resident's medical record lacked documentation of monitoring for side effects, which was confirmed by the NHA. The facility was unaware that monitoring was necessary for off-label use of anticonvulsant medications.
The facility failed to monitor adverse effects of antipsychotic medications for two residents. One resident, with schizoaffective disorder, was not assessed with an AIMS upon admission or when medication changes occurred. Another resident, with bipolar disorder, did not receive AIMS or adverse effect monitoring for lithium carbonate. These oversights were confirmed by the facility's President of Success, indicating non-compliance with the facility's psychotropic medication policy.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate. An LPN crushed and administered medications to a resident in forms contrary to the manufacturer's instructions, including extended and delayed release tablets. The resident had multiple diagnoses, and the error was confirmed by the DON.
A resident with chronic conditions, including COPD, was not offered a pneumococcal vaccine upon admission, as required by the facility's policy and CDC guidelines. The resident's medical record lacked documentation of the vaccine being offered or declined, which was confirmed by the facility's President of Success. This oversight represents a deficiency in following vaccination protocols.
A resident with a history of aggressive behavior was not adequately supervised, leading to repeated incidents of aggression towards another resident. Despite known risks and previous incidents, the facility failed to update the care plan or implement increased supervision, resulting in physical harm to another resident.
A facility failed to report a resident-to-resident altercation to the NHA and SA as required. One resident, with a history of mental health issues, threw a cup of coffee creamers and verbally threatened another resident. Despite being observed by an RN, the incident was not reported until the next day, violating the facility's policy on timely reporting of abuse allegations.
The facility did not thoroughly investigate an abuse incident where a resident threw a cup of creamers at another resident, leading to a repeat incident. Despite having policies in place, the facility failed to report the incident to administration or the SA and did not conduct necessary interviews or evidence handling.
The facility did not ensure timely physician visits for two residents, as required by regulations. One resident, with diagnoses including lymphoma, missed a scheduled visit in February, while another resident with multiple chronic conditions was not seen by a physician every 30 days for the first 90 days after admission. The facility's leadership confirmed the oversight and lack of documentation for these visits.
Failure to Report Allegation of Resident Exploitation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of exploitation to the State Agency as required by its abuse, neglect, and exploitation policy. The policy, revised 7/15/22, states that all alleged violations, including exploitation and misappropriation of resident property, must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Exploitation is defined in the policy as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The policy further requires that alleged violations be reported immediately, but not later than two hours if they involve abuse or serious bodily injury, or within 24 hours if they do not, and that results of investigations be reported to government agencies within five working days. The incident involved a resident with diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, who had intact cognition with a BIMS score of 15 and was their own decision maker. On the evening in question, an agency LPN told the resident they did not have gas money to get home, and the resident gave the LPN eight dollars, which was later returned after another nurse instructed the LPN that accepting money from a resident was unacceptable. The next day, the ADON spoke with the resident, who confirmed giving and then having the money returned, and indicated they knew the LPN from a previous facility and believed their relationship made it acceptable to give money. The ADON reported the incident to the NHA. The NHA acknowledged being informed of the incident, but determined it was not an allegation of exploitation and did not report it to the State Agency, despite the facility’s policy requiring reporting of all alleged violations.
Failure to Thoroughly Investigate Allegation of Resident Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of exploitation involving one resident. The facility’s Abuse, Neglect and Exploitation policy requires immediate and comprehensive investigations of alleged abuse, neglect, or exploitation, including identifying and interviewing all involved persons, witnesses, and others who might have knowledge of the allegation, and focusing on determining whether exploitation occurred. The resident involved had diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, and had a BIMS score of 15/15, indicating intact cognition and that the resident was their own decision maker. The resident reported that an agency LPN stated they did not have gas money to get home from work and accepted eight dollars from the resident, which was later returned. The resident stated they knew the LPN from a prior facility where the LPN had cared for them and believed their relationship made it acceptable to give the LPN money. The ADON was informed by a nurse that the LPN had accepted money from the resident and had instructed the LPN to return it. The ADON then spoke with the resident, who confirmed giving the LPN gas money and that it had been returned, and stated they felt it was acceptable due to their relationship with the LPN. After this interview, the ADON did not conduct any further investigation. The NHA was informed of the incident and determined it was not an allegation of exploitation, in part because the money was returned and the resident did not appear to have adverse psychosocial effects. The NHA confirmed that no additional residents or staff were interviewed to determine if there were similar concerns or if other residents had been affected, and the facility’s investigation contained no further interviews beyond the resident, despite policy requirements for a complete and thorough investigation of alleged exploitation.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for six residents, leading to discrepancies in their medical records. One resident with a tracheostomy did not have their tracheostomy care documented in multiple MDS assessments, despite having a medical order for such care and the presence of tracheostomy supplies. Another resident, who was discharged from Hospice services, was incorrectly documented as still receiving these services in subsequent MDS assessments. A resident prescribed antiplatelet medication was inaccurately recorded as receiving anticoagulant medication in their MDS assessments. Additionally, this resident had a Preadmission Screening and Resident Review (PASRR) Level II Screen completed, which was not reflected in their MDS assessment. Another resident's MDS assessment failed to document the administration of prescribed antianxiety medication. Further discrepancies were noted for a resident who experienced a fall resulting in a major injury, which was not recorded in their MDS assessment. This resident was also prescribed antipsychotic and antidepressant medications, which were not documented in their MDS assessments. Similarly, another resident's MDS assessment did not reflect the administration of prescribed antianxiety medication. These inaccuracies were confirmed through interviews with the facility's registered nurse responsible for MDS assessments.
Failure to Acknowledge Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendation reports were acknowledged by a physician for four residents, leading to deficiencies in medication management. For Resident 20, three out of six pharmacy recommendations were not acknowledged by a physician, and there was no follow-up for recommendations made in April, June, and July 2024. The resident was prescribed multiple medications for conditions including Parkinson's disease and bipolar disorder, and the pharmacy had recommended a gradual dose reduction for certain psychotropic drugs, which was not documented or followed up by the facility. Resident 13 also experienced a lack of physician acknowledgment for three out of nine pharmacy recommendations. The recommendations included monitoring and adjustments for medications related to diabetes, hypertension, and mental health conditions. The facility was unable to provide documentation of a physician's response to these recommendations, indicating a breakdown in the process of reviewing and acting upon pharmacy recommendations. Similarly, Resident 17 had three out of six pharmacy recommendations unacknowledged by a physician, including a dose reduction for sertraline and discontinuation of lovastatin. Additionally, the facility failed to act on a recommendation to decrease pantoprazole, despite a nurse practitioner's agreement. Resident 11's pharmacy reviews were inconsistently completed over seven months, with only two reviews available for that period. The facility lacked a process for ensuring regular pharmacy reviews and physician follow-up, contributing to these deficiencies.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide proper notification of coverage changes and financial liability to two residents when their Medicare Part A benefits ended. For one resident, identified as R26, the facility did not issue an Advanced Beneficiary Notice (ABN) form, which should have included the daily rate for which the resident would be liable if they chose to remain in the facility after their Medicare benefits ended. Despite signing a Notice of Medicare Non-Coverage (NOMNC) form indicating the end of benefits, R26 remained in the facility without receiving the necessary ABN form, as confirmed by the Nursing Home Administrator. Another resident, identified as R10, did not receive a NOMNC form when their Medicare Part A benefits ended. The facility's documentation incorrectly indicated that the termination of benefits was resident-initiated, which would not require a NOMNC form. However, interviews with the Director of Rehab and the President of Success revealed that the termination was facility-initiated, and the resident should have been provided with a NOMNC form. This oversight was acknowledged by the facility's staff during the surveyor's investigation.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who was discharged from Hospice services. The resident was admitted to the facility on Hospice services with diagnoses including diffuse large B-cell lymphoma and was receiving palliative care. The resident was discharged from Hospice services, but the facility only completed Quarterly MDS assessments following this discharge. During an interview, the Registered Nurse responsible for MDS assessments confirmed that a Significant Change MDS assessment should have been completed upon the resident's discharge from Hospice services. The Nursing Home Administrator also acknowledged that the MDS assessment should have been coded as a Significant Change MDS assessment according to the MDS manual guidelines.
Failure to Monitor and Report Significant Weight Gain
Penalty
Summary
The facility failed to ensure that a resident, identified as R11, received the necessary care and services to prevent and monitor significant weight gain. Despite the facility's Weight Monitoring policy, which requires regular weight checks and notification of significant weight changes to the physician and Registered Dietitian, R11 experienced a severe weight change of 38.93% over several months. The medical record review revealed that R11's physician was not adequately informed of the significant weight gain, and the facility did not follow the physician's order for weight monitoring after R11's return from a hospital admission. R11, who had diagnoses including Parkinson's disease, schizoaffective disorder, and bipolar disorder, was on medications that could affect appetite and weight. Despite multiple progress notes and weight assessments indicating significant weight gain, no new nutritional interventions or physician orders were documented. The facility's failure to document physician notification and to adhere to weight monitoring protocols contributed to the deficiency identified by the surveyor.
Failure to Monitor Adverse Reactions for High-Risk Medication
Penalty
Summary
The facility failed to monitor for adverse reactions of a high-risk medication, lamotrigine, prescribed to a resident diagnosed with bipolar disorder. The resident was prescribed 100 milligrams of lamotrigine once daily, but the medical record did not indicate any monitoring for adverse reactions or side effects associated with this medication. This oversight was identified during a review of the resident's medical record by a surveyor. Upon inquiry, the Nursing Home Administrator confirmed that there was no prior monitoring in place for the resident's anticonvulsant medication. The facility was not aware that monitoring for adverse reactions or side effects should be conducted for anticonvulsant medications, even when prescribed for off-label use. This lack of awareness and subsequent inaction led to the deficiency noted by the surveyor.
Failure to Monitor Adverse Effects of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure proper monitoring for adverse consequences of antipsychotic medications for two residents. Resident 11, who was admitted with diagnoses including schizoaffective disorder and bipolar disorder, was prescribed multiple antipsychotic medications such as aripiprazole and quetiapine. However, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) upon admission, when changes were made to the antipsychotic medication regimen, or when additional antipsychotic medications were prescribed. This lack of monitoring was confirmed by the facility's President of Success, who acknowledged that the necessary AIMS assessments were not conducted. Similarly, Resident 24, who had diagnoses including bipolar disorder and adverse effects of antipsychotic medication, was prescribed lithium carbonate. The facility did not perform an AIMS or implement monitoring for adverse side effects related to the antipsychotic medication upon admission. This oversight was also confirmed by the facility's President of Success, indicating a failure to adhere to the facility's psychotropic medication policy, which mandates regular monitoring and documentation of residents' responses to such medications.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate during medication administration observations. This deficiency was identified when a Licensed Practical Nurse (LPN) administered medications to a resident, R14, in forms that were contrary to the manufacturer's instructions. Specifically, the LPN crushed a 600 mg guaifenesin extended release (ER) tablet, a 20 mEq potassium chloride ER tablet, and a 20 mg omeprazole delayed release (DR) capsule, despite clear instructions not to crush or chew these medications. The error was observed during a surveyor's review of the medication administration process. R14, the resident affected by the medication errors, was admitted to the facility with multiple diagnoses, including cancer, hypertension, chronic kidney disease, dementia, and asthma. The resident's medical record indicated a physician's order allowing the crushing of medications permissible by the manufacturer. However, the LPN was unaware of the specific restrictions on the medications administered to R14. The Director of Nursing confirmed that extended and delayed release medications should not be crushed, highlighting a lapse in adherence to the facility's medication administration policy.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was offered a pneumococcal vaccine, as required by their own policy and CDC guidelines. R13's medical record lacked documentation indicating that the vaccine was offered or declined. The facility's policy mandates that each resident be assessed for pneumococcal immunization upon admission and be offered the vaccine unless contraindicated or previously immunized. However, R13's record did not reflect any such assessment or offer, despite the resident having chronic conditions like dementia, diabetes mellitus, and chronic obstructive pulmonary disease (COPD), which are risk factors for pneumococcal disease. During the survey, it was confirmed by the President of Success (VPS)-C that R13's medical record did not contain documentation of an offer or refusal of the pneumococcal immunization. R13 was admitted to the facility with a Minimum Data Set (MDS) assessment indicating intact cognition, which suggests that the resident was capable of making informed decisions regarding their health care. The absence of documentation and the failure to offer the vaccine represent a deficiency in adhering to the facility's vaccination policy and CDC recommendations.
Inadequate Supervision Leads to Resident Aggression
Penalty
Summary
The facility failed to provide adequate supervision for a resident, R1, who was known to have a history of aggressive behaviors due to schizoaffective disorder and bipolar disorder. R1's care plan included interventions such as calling family members, administering medications, and providing supervision during social gatherings. However, the care plan was not updated to reflect R1's increased aggressive behaviors towards staff and other residents. Despite multiple incidents of aggression, including verbal threats and physical actions, the facility did not implement increased supervision or other interventions to manage R1's behavior. On two separate occasions, R1 was able to enter another resident's room, R2, and engage in aggressive behavior. On the first occasion, R1 threw a Styrofoam cup of coffee creamers at R2 and verbally threatened them. The facility did not take any action to increase supervision or protect R2 after this incident. The following day, R1 was observed agitated in the hallway outside R2's room, but staff did not intervene or provide supervision. R1 subsequently entered R2's room again and threw a basket at R2, causing physical harm. The facility's failure to update R1's care plan and implement necessary interventions resulted in repeated incidents of aggression towards R2. Despite R1's history of aggressive behavior and the facility's policy on abuse prevention, there was no increased supervision or room changes to protect R2 and other residents. Interviews with staff confirmed that R1 was not on increased supervision, and interventions to redirect R1 were inconsistently applied.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the Nursing Home Administrator (NHA) and the State Agency (SA) as required by their policy. On 5/23/24, one resident entered another resident's room, threw a Styrofoam cup full of coffee creamers, and verbally threatened the other resident. Despite the incident being observed by a Registered Nurse (RN), it was not reported to the NHA or the Director of Nursing (DON) until the following morning, and the facility did not report the incident to the SA. The facility's policy mandates that all alleged violations involving abuse be reported immediately, or within a specified timeframe, depending on the severity of the incident. The involved residents had intact cognition, as indicated by their Minimum Data Set (MDS) assessments. The resident who initiated the altercation had a history of mental health issues and was at risk for inappropriate behaviors, as noted in their care plan. However, the facility did not adhere to its policy of timely reporting, resulting in a deficiency noted by the surveyor.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving two residents, R1 and R2. On 5/23/24, R1 entered R2's room and threw a Styrofoam cup full of creamers at R2. Despite this incident, the facility did not report it to administration or the State Agency (SA), nor did they conduct a thorough investigation to prevent further abuse. This lack of action resulted in another incident involving R1 and R2 the following day. R1 was admitted with diagnoses including Parkinson's disease, epilepsy, schizoaffective disorder, bipolar disorder, insomnia, and anxiety, with a BIMS score indicating intact cognition. R1's care plan noted a risk for behavior related to mental illness, including refusal of medications and inappropriate behavior. R2, admitted with diffuse large B-cell lymphoma and other conditions, also had intact cognition. The facility's policy required a thorough investigation of abuse allegations, including identifying responsible staff, handling evidence carefully, and interviewing all involved parties, but these steps were not followed in this case.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure timely physician visits for two residents, R2 and R4, as required by their policies and federal regulations. R2, who was admitted with diagnoses including large cell lymphoma and lymphedema, was not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Specifically, after being seen in January, R2 was not seen again until March, missing the required February visit. Despite being scheduled, there was no documentation to confirm the February visit occurred. Similarly, R4, who had multiple diagnoses including Parkinson's disease and chronic pain syndrome, was not seen by a physician every 30 days for the first 90 days after admission. R4 was seen by a nurse practitioner in October and December, but not by a physician, and there was no record of a physician visit in November. The facility's leadership confirmed the oversight and lack of documentation for the required physician visits for both residents.
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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