Heartland Country Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Black Earth, Wisconsin.
- Location
- 634 Center St, Black Earth, Wisconsin 53515
- CMS Provider Number
- 525521
- Inspections on file
- 19
- Latest survey
- January 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Heartland Country Village during CMS and state inspections, most recent first.
The facility failed to provide weekend activities for residents, as activity staff did not conduct activities on weekends despite being scheduled. The activity schedule was not followed, and there was no documentation of residents participating in activities. Interviews revealed a lack of awareness and adherence to the schedule, resulting in unmet activity preferences and needs for three residents.
The facility was found deficient in providing adequate food and nutrition services due to the absence of a full-time qualified dietician or director of food and nutrition services. This led to insufficient dietary support staff, failure to follow food safety standards, and inability to ensure residents received proper diets. The Nursing Home Administrator had to step in to manage meal preparation and ordering due to these staffing issues.
The facility failed to maintain sufficient dietary support staff, leading to non-dietary staff preparing meals without proper training. This resulted in residents not receiving proper nutrition, with meals often served late or not at all. Staff and residents expressed concerns about the lack of a full-time registered dietician or certified dietary manager, and the absence of essential supplies like Thick-It for residents with swallowing issues.
The facility failed to provide food in the appropriate form for two residents on altered diets, leading to an Immediate Jeopardy situation. The absence of dietary staff and lack of training resulted in unqualified personnel preparing meals, causing residents to receive incorrect diets. This deficiency posed a significant risk to the health and safety of residents with specific dietary needs.
A resident admitted for short-term rehab with intact skin developed a stage 3 pressure ulcer on the coccyx due to the facility's failure to implement preventive measures. Despite being at risk, the resident did not have a turning and repositioning schedule, and staff were unaware of the pressure injury until it reached stage 3. The facility's lack of documentation and intervention led to the development of the ulcer.
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, affecting all 22 residents. The NHA served scrambled eggs without verifying the temperature due to a non-functioning thermometer. Additionally, the kitchen had an unclean stove top, incomplete temperature logs for freezers and refrigerators, and improper storage of sugar near chemicals.
The facility's assessment failed to include specific training and competency requirements for kitchen staff, including the dietary manager, potentially affecting all 22 residents. The Nursing Home Administrator acknowledged the need for comprehensive staff training details.
The facility failed to identify and address deficiencies in the kitchen and meal service through a QAPI plan. The NHA provided a QAPI document initiated on the day of the survey, acknowledging it should have been started earlier. This oversight potentially affects all 22 residents.
A resident in an LTC facility, who is dependent on staff for mobility and self-care, was neglected by a nurse and two CNAs who refused to assist her in transferring from a wheelchair to a bed. Despite the resident's requests and a 911 call, staff did not provide necessary care, leaving her in soiled incontinence products. An EMT confirmed the neglect, and the incident was not reported to the State Agency as required.
Two residents experienced misappropriation of their hydrocodone-acetaminophen tablets by an RN, who administered the medication without their request. The discrepancy was discovered during a narcotic count, leading to the RN's termination. However, the incident was not reported to the State Survey Agency promptly. Both residents were cognitively intact and had not requested the medication. The facility failed to review the RN's license thoroughly before hiring, which had previous restrictions due to narcotic administration issues.
A facility failed to report allegations of neglect and misappropriation in a timely manner. A resident reported neglect when staff refused to assist her with a transfer, and the incident was not reported to authorities despite a 911 call. Additionally, a narcotic count discrepancy involving missing hydrocodone tablets was not reported to the State Survey Agency within the required timeframe. The facility's policies and state regulations for reporting were not followed, leading to deficiencies.
A resident reported neglect when staff refused to assist her in transferring to bed, leading to a 911 call. The facility failed to investigate or report the incident as required by policy. The NHA, unaware of any investigation, confirmed the incident was not reported to the State Agency, and no documentation was available.
A resident with multiple health conditions was not weighed according to physician orders, missing three specific dates, and was not assessed following multiple complaints of chest pain. This indicates a failure to adhere to the care plan and respond to the resident's symptoms.
A resident with dementia and Alzheimer's disease experienced an unwitnessed fall in their room, which the facility failed to investigate or analyze for root cause until three days later. Despite having a care plan to minimize falls, the facility did not adhere to its policy on timely investigation, contributing to a deficiency.
A resident with ileostomy status experienced frequent leaks due to inadequate ostomy supplies at the facility. Despite a physician's order for regular bag changes, the facility failed to maintain necessary supplies like rings and paste, leading to frequent appliance changes and family intervention to provide supplies. The Nursing Home Administrator, lacking knowledge in ostomy care, did not order the required paste, despite being informed by the resident's family.
Two residents in the facility did not receive their prescribed medications as required, with one resident missing doses of Benazepril and Furosemide, and experiencing delays in Nitroglycerin patch application. Another resident did not receive an inhaler and a weekly injection due to medication unavailability. The facility's policy mandates timely medication administration, which was not followed, and staff interviews revealed a lack of clarity in the medication ordering and administration process.
A facility failed to secure medications properly, as observed when an RN left a medication cup, including a controlled substance, unattended on a cart. A cognitively impaired resident had access to the cart, which was against the facility's policy requiring carts to be locked when out of sight. The RN admitted that medications should not be left unattended, leading to a deficiency.
The facility did not have a qualified Food Services Manager (FSM) to supervise the dietary department, affecting all residents. The FSM had been absent for a week, and the Administrator was temporarily overseeing the department. Cook1 confirmed the absence of an FSM, and the Registered Dietitian was on vacation, reducing oversight. The Administrator acknowledged the struggle to find a new FSM and implement necessary training and policies.
The facility failed to ensure proper sanitation of thermometers and appropriate thawing practices in the kitchen, affecting all residents. Observations revealed that kitchen staff did not sanitize thermometers between uses and improperly thawed and stored food, posing a risk of cross-contamination. The facility's administrator acknowledged ongoing struggles with dietary management and the need for proper training.
The facility failed to meet residents' nutritional needs due to improper portion sizes and lack of adherence to specialized diets. Observations revealed incorrect scoop sizes were used, leading to inconsistent meal portions. Staff were unaware of dietary requirements, and menu discrepancies were noted. The administration acknowledged issues in the dietary department, but improvements were not yet implemented.
The facility failed to maintain safe and clean equipment for two residents, with one using a wheelchair with cracked armrests and another having a chipped overbed table. Despite requests for replacements, the facility did not provide them, and no maintenance policy was available. The Administrator confirmed the expectation for equipment to be in safe condition.
The facility failed to provide written transfer notices to two residents during emergent hospital transfers. One resident, who was cognitively intact, did not recall seeing the transfer form, while another resident's records lacked evidence of a transfer notice. The facility's administrator acknowledged the expectation for such notices, indicating a gap in protocol adherence.
The facility failed to provide written bed hold notices to two residents upon their emergent hospital transfers, as required by policy. Despite obtaining verbal consent for a bed hold for one resident, there was no documentation of written notices for either resident, as confirmed by the Regional Nurse Consultant.
The facility failed to ensure accurate MDS assessments for three residents, affecting care planning. One resident's antidepressant was misclassified as an anti-anxiety medication. Another resident's MDS inaccurately coded anticoagulant use and omitted hospice services. A third resident's pressure ulcer was not correctly documented. These errors were confirmed by staff.
The facility failed to conduct and document care conferences for three residents, impacting their participation in care. Resident 4 had only two care conferences since admission, with one undocumented and lacking interdisciplinary input. Resident 12, receiving hospice services, reported no care conferences, confirmed by the Hospice Home Care Manager. Resident 13 also did not recall any care conferences, with no documentation found by the Regional Nurse Consultant.
A facility failed to provide a discharge summary with a recapitulation of a resident's stay, as required by policy. The resident, who had intact cognition, was discharged with a diagnosis related to orthopedic aftercare. The discharge note mentioned the resident's excitement to return home and plans for outpatient rehab but lacked a comprehensive summary. The absence of this summary was confirmed by the Administrator and Regional Nurse Consultant.
A facility failed to ensure proper cleaning of a resident's CPAP machine, masks, and tubing, as required by both facility policy and manufacturer guidelines. The resident, who has chronic obstructive pulmonary disease and sleep apnea, expressed fear of using the CPAP due to concerns about germs. Facility records lacked documentation of CPAP cleaning, and the Director of Nursing confirmed the resident's non-use of the machine.
The facility failed to ensure an opened vial of Aplisol tuberculin purified protein derivative (PPD) was properly dated and discarded within the manufacturer's specified timeframe. An LPN observed an undated open vial in the medication room, and the Regional Nurse Consultant confirmed the vial was past the 30-day usage period. The facility's policy did not address outdated medication, leading to this deficiency.
A resident with Alzheimer's and dementia was not provided with the prescribed mechanical soft diet and thickened liquids, leading to potential safety risks. Observations revealed the resident received regular texture foods and non-thickened liquids, contrary to physician orders. Staff interviews indicated a lack of awareness and understanding of the resident's dietary needs, with the facility administrator acknowledging challenges in dietary management and training.
The facility failed to maintain proper infection control in the laundry area, with no barrier between clean and dirty areas and washing machine drainpipes below floor level. Observations included mineralization and a dripping liquid on the washer hose. The Maintenance Director had not assessed the area, and the Administrator acknowledged the need for improvements.
The facility failed to maintain a pest-free environment in the kitchenette, as fruit flies were observed in a cabinet with food items. The Maintenance Director was unaware of the issue until it was pointed out, despite having heard about it a week earlier. He removed the contaminated food but acknowledged the need for further intervention as fruit flies were still present during a follow-up observation.
The facility did not post accurate daily nurse staffing information as required by policy. An observation found that the posted information was outdated and lacked necessary details such as the facility name and current census. The Administrator confirmed the deficiency, which could affect the understanding of staff availability for resident care.
A resident with severe cognitive impairment and multiple diagnoses expressed increased leg and hip pain. Despite recognizing the change in condition and ordering an x-ray, the facility failed to provide ongoing monitoring and assessment until the x-ray results revealed a left hip fracture. The lack of documentation and monitoring led to a delay in identifying the fracture and ensuring appropriate care.
The facility failed to adequately assess and manage a resident's increased pain, lacking proper documentation and care planning for non-verbal pain indicators and acceptable pain levels. Despite the resident's severe cognitive impairment, the facility did not follow its policy for acute pain assessment, leading to unmanaged pain and insufficient interventions.
The facility did not adhere to professional standards for food service safety, resulting in several deficiencies. One resident was served non-pasteurized eggs with runny yolks, increasing the risk of Salmonella infection. The facility lacked a policy on the use of unpasteurized eggs and safe handling procedures for shell eggs. Staff were uncertain if the eggs served were pasteurized and acknowledged serving eggs with runny yolks upon request. Observations also noted improper hand hygiene practices by a cook and inadequate labeling of frozen food items. Additionally, food temperatures were not consistently recorded before placing items in hot holding, posing a risk of foodborne illness to residents.
The facility failed to ensure a clean and homelike environment for its residents, as evidenced by observations of dust and debris buildup in resident rooms and common areas. Residents and a representative voiced concerns about cleanliness, and staff interviews revealed that housekeeping was expected to clean daily but was understaffed.
The facility failed to ensure that two residents received scheduled showers, as required by their care plans. Documentation was inconsistent, and staff did not always record refusals or provided showers, leading to lapses in personal hygiene care.
Failure to Provide Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support resident choice of activities based on comprehensive assessments and care plans for three residents. The activity staff did not conduct activities on weekends in November, December, and January, despite scheduling staff to come in. There was no schedule for residents on these weekends, and no documentation of the residents participating or being offered activities during these months. The facility's activity schedule was distributed to residents and posted in the main hallway, but weekend activities were left to the discretion of the manager on duty, which changed every weekend. The Activity Director confirmed that she only worked a few weekends and that other managers did not conduct activities as scheduled. Interviews with various staff members, including the Nursing Home Administrator, revealed a lack of awareness and adherence to the weekend activity schedule, resulting in no activities being conducted on most weekends. The residents involved had specific activity preferences and needs documented in their care plans, but there was no evidence of these being met. One resident preferred in-room activities and occasional musical events, another enjoyed morning activities and served as the resident council president, and the third resident liked socializing and required assistance to attend activities. Despite these documented preferences, there was no record of activities being offered or attended by these residents during the specified months.
Deficiency in Food and Nutrition Services Due to Lack of Qualified Staff
Penalty
Summary
The facility was found to be deficient in providing adequate food and nutrition services due to the absence of a full-time qualified dietician or a director of food and nutrition services. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility lacked a full-time registered dietician (RD) or a certified dietary manager (CDM) to ensure effective nutritional and dietary services for all 22 residents. The deficiency was considered an immediate jeopardy situation, indicating a reasonable likelihood for serious harm, which began on October 30, 2024. The surveyors noted that the facility did not have dietary policies readily available, and the Nursing Home Administrator (NHA) was unable to locate them when requested. Interviews with staff, including a dietary aide and a new employee, confirmed the absence of a dietary manager and a full-time RD. The NHA was observed cooking meals due to the lack of qualified dietary staff, and there were issues with meal ticket management and food ordering, which the NHA had to address personally. The deficiency led to several problems, including insufficient dietary support staff to provide meals, failure to follow accepted standards of practice for food safety and sanitation, and the inability to ensure residents received proper diets as ordered. These issues were compounded by the lack of a system to ensure meal tickets were available and the absence of necessary dietary products like Thick-It for residents with specific dietary needs.
Removal Plan
- All staff will be educated prior to their next working shift.
- CDM started working.
- We currently employ a registered dietician who works. The RD will review and sign off on all competencies initiated by the CDM prior to QAPI Meeting.
- Prior to food and nutritional service staff working, a competency to be completed by the CDM, with sign off by the RD.
- Competency checks for all food and nutritional services employees will be completed until all dietary staff are checked off. No dietary staff will work until competency checked.
- All staff were trained on Serve Safe food handling and sanitation of kitchen and dishroom. All new staff will be required to complete training and competency checkoff by the CDM with subsequent sign off by the RD.
- In the event of a staff call off, the staff shall first contact the CDM. If the CDM cannot be reached, all staff will contact the NHA for staffing assistance.
- In the event of a call in, only qualified staff will work in the kitchen (Serve Safe certified and competencies checked off).
- The schedule will be developed by the certified dietary manager and provided in advance for the food and nutritional services employees.
- The dietary schedule will remain posted and updated by the CDM as needed in a visible area of the kitchen.
- The CDM will provide education to all dietary staff on the following: emergency preparedness plan, scheduling, competencies and audits.
- The CDM/Administrator/Designee will conduct audits.
- All staff working in the dietary department will have the competency checks completed.
- Schedule completed for dietary staffing.
- The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement committee for patterns, trends, and continued recommendations for process monitoring and improvement.
Inadequate Dietary Staffing and Training Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure there were sufficient dietary support staff to carry out the functions of the food service department, which affected all 22 residents. Observations revealed that the Nursing Home Administrator (NHA) and other non-dietary staff were preparing and serving meals without proper training or competencies. This situation led to an immediate jeopardy finding, as the facility did not have a full-time registered dietician or certified dietary manager, and the kitchen was short-staffed. The NHA was observed cooking meals on multiple occasions, and there were instances where no dietary aide was present. Interviews with staff and residents highlighted the severity of the staffing issues. A dietary aide confirmed being the only one at the facility, and a registered nurse reported that meals were often served late due to the lack of a cook. A certified nursing assistant mentioned that resident diets were not being followed, and another CNA admitted to cooking meals without receiving any training or competency checks. Residents expressed concerns about not receiving proper nutrition, with one resident stating that their health was at risk due to incorrect diets being served. The deficiency was further evidenced by an incident where residents did not receive supper on time due to the absence of kitchen staff. Nursing staff had to prepare makeshift meals, and there was a lack of essential supplies like Thick-It for residents with swallowing issues. Family members and staff expressed concerns about the quality of care and the anxiety caused by the late meals. The facility's failure to maintain adequate dietary staffing and ensure staff competency led to a reasonable likelihood of serious harm to the residents.
Removal Plan
- All staff will be educated prior to their next working shift.
- The CDM and Administrator will ensure dietary staff are competent and sufficient to meet resident needs to include: Resident needs and preferences are met, food supply is available to meet resident needs.
- There are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety.
- Dietary staff received education on preparing altered diets per physician orders by the Certified Dietary Manager (CDM).
- In the event of a staffing concern, staff are to contact the CDM.
- Back-up staffing will include dietary staff and department head staff that have completed dietary department competencies.
- Back up emergency food supply put together with location and menu items to meet nutritional servings and portions.
- The administrator/designee will conduct audits to include the following: Observed and interview residents to determine if dietary needs are being met and dietary orders are followed.
- Complete observations and/or interviews indicate there are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety.
- The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement.
Failure to Provide Altered Diets as Ordered
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents on altered diets. Specifically, two residents, both with severe cognitive impairments and requiring specialized diets, did not receive meals in the appropriate texture and consistency as per their physician orders. The facility lacked the necessary Thick-It product to thicken liquids for residents with swallowing issues, and staff were not trained or competent in preparing altered diets. This deficiency led to an Immediate Jeopardy situation, indicating a reasonable likelihood for serious harm. The deficiency was observed through multiple instances where the Nursing Home Administrator and other untrained staff were cooking meals due to the absence of dietary staff. The facility had no dietary manager for several months, and the agency cook was unreliable, leading to situations where meals were not served on time or in the correct form. Staff, including CNAs and nurses, reported that they had to step in to prepare meals without proper training or competency checks, resulting in residents receiving incorrect diets. Interviews with staff revealed that there were ongoing issues with meal tickets not being available or accurate, and residents were sometimes served thin liquids instead of the required thickened consistency. The lack of proper dietary management and training led to residents with specific dietary needs not receiving the appropriate meals, which posed a significant risk to their health and safety.
Removal Plan
- The NHA/Director of Nursing (DON)/ Certified Dietary Manager (CDM) or designee immediately checked to ensure that the identified residents received the correct altered diet.
- The NHA/DON/CDM or designee completed an audit of all tray tickets to ensure that all diet orders match the tray tickets for all facility residents and reviewed all resident diets to ensure residents received the correct diet as ordered by the physician.
- The NHA/DON/CDM or designee reviewed all residents who receive altered texture diets. Orders were verified and updated as deemed appropriate.
- Dietary care plans were reviewed for accuracy and updated to reflect any new orders and recommendations for all residents by the DON/CDM/NHA or designee.
- All staff education initiated to ensure that physician order, including appropriate dietary recommendations are in place for all residents. Staff will receive education prior to starting their next working shift by DON/Administrator.
- All staff educated initiated on the procedure on tray ticket system for resident meal delivery and appropriate diet. Competency and validation will be completed on staff to ensure that tray ticket is present on meal tray, that the meal validates what the tray ticket indicates is the appropriate diet for the resident. Staff will receive education prior to starting their next working shift by CDM/DON/ or Administrator. Education will also include what to do if there is no ticket or if the tray ticket does not match what is on the actual resident plate or tray.
- All staff education initiated on the procedure on tray ticket system for resident meal delivery and appropriate diet. Competency and validation will be completed on staff to ensure that tray ticket is present on meal tray, that the meal validates what the tray ticket indicates is the appropriate diet for the resident. Staff will receive education prior to starting their next working shift by CDM/DON/NHA. Education will also include what to do if there is no ticket or if the tray ticket does not match what is on the actual resident plate/tray.
- All staff education initiated regarding immediate steps to take if the tray ticket does not match the meal on the tray and what immediate steps to take to ensure that resident receives appropriate therapeutic diet. Staff will receive education prior to starting their next working shift NHA/DON.
- Dietary staff educated on menus and recipes to properly make any altered textured diets per the physician orders by the CDM.
- Staff will be able to verbalize where the menus are located and where they can obtain the recipe for making therapeutic altered diets.
- Tray ticket system has been created to reflect current diet orders for all residents by facility CDM.
- Facility policies and procedures including: (Acceptance of Therapeutic Diet) reviewed by CDM and remain up-to-date.
- QAPI (Quality Assurance and Performance Improvement) for cooks to understand how to follow the recipes specific to altered textured diets and where they would obtain those recipes. Audit 2 times per week, and monthly times 6 months to ensure correct consistency for altered diets. All results will be reviewed by the QAPI Committee for trends and ongoing process improvement.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. A resident, admitted for short-term rehabilitation, initially had intact skin but developed a stage 3 pressure injury on the coccyx during their stay. The facility's policy required assessment and documentation of risk factors for pressure sores, but there was no evidence of a pressure injury upon admission, and the injury was not identified until it reached stage 3. The resident had several medical conditions, including COPD, type 2 diabetes, and chronic pain syndrome, which could contribute to skin integrity issues. Despite being at risk for pressure sores, as indicated by Braden Scale scores, the facility did not implement necessary interventions such as turning and repositioning schedules. The resident refused an air mattress, but there was no documentation of alternative measures being taken to prevent pressure injury development. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's pressure injury and the absence of a turning and repositioning schedule. The facility's failure to implement preventive measures and adequately monitor the resident's skin condition led to the development of a facility-acquired stage 3 pressure injury.
Deficiency in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 22 residents. During an observation, the Nursing Home Administrator (NHA A) was seen preparing scrambled eggs and attempted to take the temperature with a non-functioning thermometer. Despite acknowledging the issue, NHA A proceeded to serve the eggs without verifying the temperature. Later, a working thermometer was presented, indicating the previous one needed new batteries. Additionally, during a kitchen tour, the surveyor noted that the stove top was unclean, with burnt food and crumbs present, and was informed by NHA A that it would not be used until cleaned. Temperature logs for the freezers and refrigerators had multiple gaps, showing that temperatures were not consistently recorded. Furthermore, a container of sugar was improperly stored below the sink next to chemicals, which NHA A acknowledged was incorrect. These observations highlight the facility's failure to adhere to its policy on preventing foodborne illness through proper food handling and storage practices.
Incomplete Facility-Wide Assessment for Staff Competency
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all relevant details necessary to provide care and services to meet the individual needs of its residents. The assessment, updated on November 3, 2024, outlined various services provided based on resident needs, such as individualized dietary requirements, specialized diets, and cultural or ethnic dietary needs. However, it did not specify the training and competency requirements for kitchen staff, including the dietary manager. This omission was identified during an interview with the Nursing Home Administrator, who acknowledged the need for the facility assessment to include comprehensive staff training and competency details, particularly for kitchen staff. This deficiency has the potential to affect all 22 residents residing in the facility.
Failure to Implement QAPI Plan for Kitchen and Meal Service
Penalty
Summary
The facility did not identify issues requiring quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct identified quality deficiencies. This oversight has the potential to affect all 22 residents. Specifically, the facility failed to identify key areas of deficient practice in the kitchen and meal service and did not implement action plans to address these deficiencies. During a survey, the Nursing Home Administrator (NHA) was asked about any ongoing Quality Assurance Performance Improvement (QAPI) activities related to the kitchen and meal areas. The NHA provided a QAPI plan document that was initiated on the same day of the survey, indicating that the plan was not in place prior to the surveyors' arrival. The NHA acknowledged that a QAPI plan for the kitchen should have been started earlier.
Neglect of Resident by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from neglect by a nurse and two CNAs, as evidenced by an incident where the resident was refused assistance in transferring from a wheelchair to a bed. The resident, who is cognitively intact and dependent on staff for mobility and self-care, reported feeling lost and fearful for her safety, leading her to call emergency services for help. The facility's policy on abuse prevention and reporting was not followed, as the incident was not documented in the grievance log, and there was no evidence of a thorough investigation or reporting to the proper authorities. The resident, who has multiple medical conditions including congestive heart failure, anxiety disorder, and chronic kidney disease, was left in her wheelchair for an extended period without assistance, despite her requests for help. The resident also reported being left in soiled incontinence products, which staff refused to change. An EMT who responded to the 911 call confirmed the resident's account and noted that the nurse involved refused to assist the resident even with EMS present, citing fear for her safety and nursing license. The incident was not reported to the State Agency as required, and the new Nursing Home Administrator was unaware of any investigation or corrective actions taken following the incident. The EMT's professional opinion was that the incident constituted neglect, and the facility's failure to address the situation appropriately highlights a significant deficiency in protecting residents from neglect and ensuring their well-being.
Misappropriation of Resident Medications by RN
Penalty
Summary
The facility failed to protect residents from misappropriation of property, specifically involving the wrongful use of hydrocodone-acetaminophen tablets prescribed to two residents, R1 and R10. Between November 26 and November 28, 2024, three tablets for R1 and two tablets for R10 went missing. The discrepancy was discovered during a narcotic count on November 28, 2024, which revealed that the count was incorrect. The facility's investigation concluded that RN S was responsible for the misappropriation, leading to her termination. However, the incident was not reported to the State Survey Agency in a timely manner. R1, who was admitted with multiple diagnoses including congestive heart failure and chronic pain, was found to have been administered hydrocodone tablets by RN S on three occasions, despite not requesting them. R1's Medication Administration Record indicated that she had not requested her PRN Norco in the last 30 days, and she declined narcotics due to side effects. Similarly, R10, who was also cognitively intact, did not request his PRN hydrocodone on the dates it was administered by RN S. Both residents were cognitively intact, as indicated by their Brief Interview of Mental Status scores. The facility's failure to report the incident promptly was highlighted during interviews with staff, including the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON). The NHA acknowledged that the self-report was submitted late, and there was uncertainty about the required reporting timeframe. Additionally, the facility did not conduct a thorough review of RN S's license prior to her employment, which had previous restrictions due to narcotic administration issues. This oversight contributed to the hiring of RN S, who was later found to have misappropriated the medications.
Failure to Timely Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of resident property in a timely manner, as required by state law and facility policy. The first incident involved a resident who reported neglect on 10/31/24, when staff refused to assist her in transferring from her wheelchair to her bed. This incident was not reported to the State Survey Agency or law enforcement, despite the resident having called 911. The Nursing Home Administrator (NHA) was unaware of the incident until informed by the Chief Executive Officer (CEO) and mistakenly believed it had been reported. The second incident involved the misappropriation of narcotics, specifically three hydrocodone tablets, discovered missing during a narcotic count on 11/28/24. The facility suspended the involved nurses pending investigation and notified the County Sheriff's Department. However, the incident was not reported to the State Survey Agency until 12/11/24, well beyond the required 24-hour reporting window. The NHA acknowledged the delay and confirmed that medication diversion is considered misappropriation, which requires prompt reporting. Both incidents highlight the facility's failure to adhere to its own policies and state regulations regarding the timely reporting of abuse, neglect, and misappropriation. The facility's policy mandates immediate reporting of such allegations to the administrator and relevant authorities, yet these procedures were not followed, resulting in deficiencies noted by the surveyor.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident. On 10/31/24, the facility became aware of an incident where a resident alleged neglect by staff, specifically that they refused to assist her in transferring from her wheelchair to her bed. The resident, visibly upset, reported the incident to Emergency Medical Services (EMS) and the sheriff, who responded to her 911 call. The EMS report labeled the situation as possible elder abuse. Despite this, the facility did not assess or interview residents, take statements, conduct a facility audit, or report the incident to law enforcement as required by their policy. The facility's policy mandates that all allegations of abuse or neglect be thoroughly investigated and reported to the appropriate authorities. However, the Nursing Home Administrator (NHA), who started employment after the incident, was unaware of any investigation or documentation related to the incident. The NHA confirmed that the incident was not reported to the State Agency, as required. Additionally, there was no evidence of any education or audits conducted to prevent recurrence. The facility was unable to produce any documentation related to the incident upon request by the surveyor.
Failure to Monitor Weight and Assess Chest Pain
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards of practice for one resident. The resident, who was admitted with multiple diagnoses including congestive heart failure, chronic kidney disease stage 4, and atrial fibrillation, was not weighed according to the physician's order. The physician's order required daily weight monitoring with specific instructions to update the medical doctor if there was a weight change of 3 pounds in a day or 5 pounds in a week. However, the resident was not weighed on three specific dates, which is a deviation from the prescribed care plan. Additionally, the resident reported experiencing chest pain on several occasions, but there was no documented assessment by the facility staff following these complaints. The lack of assessment occurred despite the resident's comprehensive care plan, which included monitoring and documenting vital signs and notifying the medical doctor of significant abnormalities. This oversight indicates a failure to adhere to the care plan and respond appropriately to the resident's symptoms.
Failure to Investigate Resident Fall Timely
Penalty
Summary
The facility failed to ensure a safe environment free from hazards and did not provide adequate supervision and assistive devices for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and unsteadiness on feet, sustained an unwitnessed fall in their room. The fall occurred early in the morning, and the facility did not investigate or attempt to determine a root cause analysis until three days after the incident. The facility's policy on Fall Prevention and Risk Assessment emphasizes the importance of providing a safe environment and minimizing potential injuries due to falls. It also highlights the need for early identification of risk factors and staff intervention to reduce fall risks. However, in this case, the facility did not adhere to its policy, as evidenced by the lack of timely investigation and analysis of the fall incident involving the resident. The resident's care plan indicated a history of falls, with interventions such as a toileting program and early get-up list to minimize falls. Despite these measures, the resident experienced a fall, and the facility's failure to promptly investigate and analyze the incident contributed to the deficiency. The Assistant Director of Nursing acknowledged that falls should be investigated timely to determine a root cause analysis, which was not done in this instance.
Inadequate Ostomy Supplies for Resident
Penalty
Summary
The facility failed to provide adequate colostomy supplies for a resident, identified as R3, who required such services. R3 was admitted with multiple diagnoses, including ileostomy status, and had a physician's order to change the ileostomy bag every three days or as needed. However, due to high output and frequent leaks, the facility was changing R3's ostomy appliance multiple times per shift. Despite this need, the facility did not maintain an adequate supply of necessary ostomy supplies, such as rings and paste, which are crucial for securing the ostomy bag and extending its wear time. This deficiency was highlighted by the fact that R3's family member, FM E, had to order paste from Amazon due to the facility's failure to provide it. The facility's supply ordering policy was not effectively implemented, as the Nursing Home Administrator, who was responsible for ordering supplies after the abrupt departure of the previous Director of Nursing, lacked knowledge about ostomy supplies. Despite being informed by FM E about the specific needs and item numbers for R3's ostomy care, the facility's orders did not include the necessary paste. This ongoing issue led to FM E expressing frustration and concern over the inadequate supply, which had been communicated to the facility multiple times without resolution. The lack of a specific policy and procedure for colostomy/ileostomy care further contributed to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, R1 and R2, as evidenced by missed and delayed medication administration. R1 did not receive her prescribed Benazepril on two occasions and her Nitroglycerin patch was administered late multiple times. Additionally, R1 missed a dose of Furosemide. The facility's policy requires medications to be administered in a timely manner, within one hour of the prescribed time, which was not adhered to in these instances. R1, who was admitted with multiple diagnoses including congestive heart failure and hypertension, was cognitively intact as per her recent MDS assessment. Despite this, there were no documented reasons for the missed doses of Benazepril and Furosemide, and the Nitroglycerin patch was consistently applied and removed late. The Assistant Director of Nursing (ADON) was unable to provide a reason for the missed medications and confirmed that medications should be administered as ordered. R2, admitted for short-term rehabilitation, also experienced issues with medication availability. R2 did not receive a prescribed inhaler and a weekly injection on the specified dates due to the medications not being available. Interviews with the ADON and other nursing staff revealed a lack of clarity and follow-up regarding the process for ensuring medication availability and administration. The facility's failure to ensure timely medication delivery and administration for R2 was evident, with no follow-up notes or actions documented to address the unavailability of medications.
Unsecured Medication Cart and Inadequate Drug Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to accepted professional principles. During a survey, it was observed that a registered nurse (RN K) dispensed several medications, including a controlled substance, into a medication cup and left it unattended on a medication cart. This cart was accessible to a cognitively impaired resident, who was using the cart to self-propel down the hallway. The facility's policy requires that medication carts be kept closed and locked when out of sight of the medication nurse or aide, and no medications should be left on top of the cart. The surveyor observed multiple instances where RN K prepared and administered medications to different residents, leaving the medication cup unsecured and accessible in the hallway. This included a controlled substance, tramadol, which should be stored behind at least two differently keyed locks. Despite being aware of the policy, RN K admitted that medications should not be left unattended. The repeated inaction of securing the medication cart and leaving medications accessible to residents and others in the hallway led to the deficiency.
Lack of Qualified Food Services Manager in Dietary Department
Penalty
Summary
The facility failed to employ a qualified Food Services Manager (FSM) to supervise the dietary department, potentially affecting all 23 residents. The facility's policy requires the daily functions of the Food Services Department to be under the supervision of a qualified FSM. However, interviews revealed that the FSM had been absent for about a week, and the Administrator had been overseeing the department in the interim. Cook1 confirmed the absence of an FSM and mentioned relying on other cooks for guidance. The Administrator acknowledged the lack of an FSM and stated that they were in the process of hiring a new one. Additionally, the Registered Dietitian, who typically visits once a week, was on vacation, further impacting the department's oversight. The Administrator admitted that the dietary department was struggling to find a manager willing to implement the necessary training and policies.
Improper Food Safety Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation of thermometers and appropriate thawing practices in the kitchen, affecting all 23 residents. Observations revealed that Cook1 and Cook2 did not sanitize thermometers between uses, instead wiping them with dry or damp cloths, which is not in accordance with the facility's guidelines or the 2022 FDA Food Code. Cook1 admitted to not being instructed on proper sanitation methods, while Cook2 was unaware of the location of alcohol wipes and believed running the thermometer under water was sufficient. Additionally, improper thawing and storage practices were observed. Frozen turkey lunchmeat was left thawing on a counter instead of under refrigeration, and raw beef was stored above uncovered raw potatoes in the walk-in refrigerator, posing a risk of cross-contamination. Cook2 acknowledged the error and moved the meat to a lower shelf. The facility's administrator admitted to ongoing struggles with dietary management and the need for proper training and policy implementation.
Deficiencies in Dietary Management and Meal Preparation
Penalty
Summary
The facility failed to adhere to dietary requirements and portion sizes as outlined in their menu and diet extensions, affecting the nutritional needs of residents. Observations and interviews revealed that the facility did not provide the correct portion sizes for meals, as evidenced by the use of incorrect scoop sizes for serving food. Residents reported inconsistencies in meal portions, with some meals being undersized and others oversized. Additionally, the facility did not provide the correct foods for specialized diets, such as a renal diet, as ordered by the attending physician. Interviews with residents and staff highlighted a lack of awareness and understanding of dietary requirements and menu extensions. One resident on a renal diet reported not receiving the appropriate meals, and staff members were unsure of the dietary needs of residents, including those on specialized diets. The facility's menu and diet extensions did not match, leading to discrepancies in meal preparation and serving. Staff members, including cooks, were not familiar with the concept of menu extensions and were unsure of the correct portion sizes to serve. The facility's administration acknowledged the issues within the dietary department, citing challenges in finding a manager to provide proper training and implement necessary policies. The administrator admitted to being aware of the problems and indicated that the facility was in the process of improving the dietary department. However, at the time of the survey, these deficiencies in dietary management and meal preparation had not been addressed, resulting in potential interference with residents' medical conditions and nutritional needs.
Deficiency in Equipment and Furniture Maintenance
Penalty
Summary
The facility failed to maintain a safe and clean environment for two residents, leading to potential risks of injury and infection. One resident was observed self-propelling a wheelchair with cracked and worn vinyl armrests, which had been in that condition for about a year. Despite the resident's request for new armrests, the facility did not provide replacements. Another resident, who was blind, had an overbed table with a chipped surface, creating a non-cleanable and rough area. These conditions were confirmed by the facility's Administrator and Maintenance Director during their observations. The surveyor requested the facility's policy on resident equipment and furniture maintenance, but no policy was provided. The Administrator expressed an expectation that the overbed tray and wheelchair armrests should be in a cleanable and safe condition. The lack of maintenance and replacement of damaged equipment and furniture led to the deficiency, as it compromised the residents' right to a safe, clean, and comfortable environment.
Failure to Provide Written Transfer Notices for Emergent Hospital Transfers
Penalty
Summary
The facility failed to provide a written transfer notice containing all required information to two residents or their representatives during emergent hospital transfers. Resident 6, who was cognitively intact, was transferred to the hospital after being found with unstable vitals and unresponsive. Although a transfer notice was documented in the electronic medical record with a handwritten note indicating verbal consent, the resident later stated she did not recall seeing the form. This indicates a lack of proper communication and documentation regarding the transfer. Similarly, Resident 23, who had multiple medical diagnoses including acute and chronic respiratory failure, was transferred emergently after an incident where the resident was found on the floor. The facility's records did not show evidence of a written transfer notice being provided. The Regional Nurse Consultant could only provide an E-Interact Transfer form intended for hospital staff, not a proper transfer notice for the resident or their representative. The facility's administrator acknowledged the expectation for a written notice to be provided upon emergency transfer, highlighting a gap in adherence to this protocol.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to two residents, R6 and R23, upon their emergent transfers to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed hold policies at least twice: once in advance of any transfer and again at the time of transfer or within 24 hours if the transfer is an emergency. However, during the review, it was found that R6, who was transferred to the hospital due to unstable vitals and a dislodged catheter, did not receive a written bed hold notice. Although verbal consent for a bed hold was obtained, there was no documentation of a written notice being provided. Similarly, R23, who was transferred to the hospital after an incident involving unsteady gait and a fall, also did not receive a written bed hold notice. The facility's records, including the Miscellaneous and Assessment tabs of R23's electronic medical record, showed no evidence of such a notice being provided. The Regional Nurse Consultant confirmed that there was no information found regarding the provision of written bed hold notices for these emergent transfers, indicating a lapse in following the facility's policy.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, which could potentially affect their care planning and services. For one resident, the MDS inaccurately coded an antidepressant medication, Sertraline HCl, as an anti-anxiety medication. This error was confirmed by the MDS Coordinator during an interview. Another resident's MDS inaccurately coded the use of anticoagulant medication, despite the resident only receiving aspirin, which should not be coded as an anticoagulant according to the RAI Manual. Additionally, the resident was on hospice services with a terminal prognosis, but this was not accurately reflected in the MDS assessments. The MDS Coordinator and RNC confirmed these inaccuracies during interviews. The third resident had a stage three pressure ulcer on the heel that was not correctly coded in the MDS since admission. The resident reported the pressure injury started before admission, and the RNC confirmed the coding error. The RAI Manual provides specific guidelines for coding pressure ulcers, which were not followed in this case.
Failure to Conduct and Document Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were conducted for three residents, which affected their right to participate in their care. The facility's policy required care conferences to be conducted quarterly, annually, and upon admission, involving a team of health professionals. However, for Resident 4, only two care conferences were conducted since admission, with one not documented, and no other interdisciplinary staff were documented as attending. Resident 4 expressed concerns about weight gain and dietary preferences, and the Social Worker noted an increase in behaviors, but the care conference lacked comprehensive interdisciplinary input. Resident 12, who was receiving hospice services, reported that care conferences were not held, and the facility's records lacked documentation of such meetings. The Hospice Home Care Manager confirmed that they had not been invited to any care conferences for this resident. Similarly, Resident 13 did not recall being invited to any care conferences, and the facility's records showed no documentation of such meetings. The Regional Nurse Consultant was unable to find any care conference documentation for Resident 13, indicating a systemic issue in conducting and documenting care conferences as per the facility's policy.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary that included a recapitulation of the resident's stay for one resident, identified as R19, who was reviewed for discharges among a sample of 16 residents. The facility's policy, effective 02/21/24, mandates that the discharge summary should include a recapitulation of the resident's stay and a final summary of the resident's status at discharge. R19 was admitted and later discharged with a diagnosis related to orthopedic aftercare. The discharge Minimum Data Set indicated that R19 had intact cognition with a BIMS score of 15 out of 15. A progress note labeled as a Discharge Summary mentioned the resident's discharge to home and plans for outpatient rehabilitation but lacked a comprehensive summary of the resident's stay and status. During an interview, the Administrator and Regional Nurse Consultant confirmed the absence of the required discharge summary for R19.
Failure to Maintain CPAP Equipment Cleanliness
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not ensuring the CPAP machine, masks, and tubing were cleaned according to guidelines. The facility's policy and the manufacturer's guidelines both emphasize the importance of regular cleaning to prevent contamination and infection. However, the resident expressed fear of using the CPAP machine due to concerns about germs in the tubing, indicating a lack of proper cleaning. The resident's medical history includes chronic obstructive pulmonary disease, sleep apnea, and other conditions that necessitate the use of a CPAP machine. The facility's records, including the Medication Administration Record and Treatment Administration Record, showed no documentation of CPAP equipment cleaning. Despite orders for CPAP use, there were no specific orders for cleaning the equipment. The Director of Nursing confirmed the presence of the CPAP machine at the resident's bedside but acknowledged that the resident did not use it. This oversight in maintaining the CPAP equipment according to the required standards led to the deficiency identified during the survey.
Failure to Properly Date and Discard Opened Aplisol Vial
Penalty
Summary
The facility failed to ensure that an opened vial of Aplisol tuberculin purified protein derivative (PPD) was not available for resident use, as it was undated and potentially outdated. During an observation of the long-term care medication room, a medicine bottle labeled Aplisol, dated 08/14/24, was found with vials of PPD inside. One of these vials was open, with the cap removed from over the rubber stopper, and lacked a date indicating when it was opened or when it would expire. This was confirmed by a Licensed Practical Nurse (LPN) during the observation. The facility's policy on medication storage did not address outdated medication, and the policy on medication labeling and storage required that multi-dose vials be dated and discarded within 28 days unless the manufacturer specified otherwise. The manufacturer's instructions on the Aplisol box indicated that once entered, the vial should be discarded after 30 days. The Regional Nurse Consultant confirmed that the open vials were good for 30 days, and the Administrator expressed an expectation that medications would be dated when opened and not stored past the manufacturer's expectations of life after opening.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a resident with the appropriate mechanically altered diet and thickened liquids as ordered by the physician. The resident, who had diagnoses including Alzheimer's disease, dementia, and mild-protein calorie malnutrition, was supposed to receive a mechanical soft diet with nectar thick liquids to prevent aspiration. However, during multiple meal observations, the resident was served regular texture foods and non-thickened liquids, contrary to the dietary orders. On several occasions, the resident received meals that did not match the prescribed minced and moist texture or thickened liquid consistency. For instance, during a lunch observation, the resident was served regular texture chicken and rice instead of the prescribed minced and moist items. Similarly, during breakfast, the resident received regular scrambled eggs and bacon instead of the mechanically altered diet. The dietary staff, including a cook and a CNA, were unaware of the resident's special dietary needs, leading to the resident being served inappropriate meals. Interviews with facility staff revealed a lack of awareness and understanding of the resident's dietary requirements. The CNA and cook both admitted to not knowing the resident was on a special diet, and the cook was unfamiliar with the term 'minced and moist.' The facility administrator acknowledged ongoing struggles with dietary management and training, indicating systemic issues in ensuring compliance with dietary orders.
Infection Control Deficiency in Laundry Area
Penalty
Summary
The facility failed to maintain a proper infection prevention and control program in the laundry processing area. During a tour with the Infection Preventionist, it was observed that there was no barrier between the clean and dirty laundry areas. Clothing was hanging on a rod and a linen cart was covered with a mesh blue cart cover, both located near the washing machines. The Infection Preventionist confirmed the lack of a barrier between the dirty and clean areas. Additionally, the washing machine drainpipes were below floor level, which could lead to contamination in the event of a sewer backup. A blue substance and mineralization were observed on the corrugated hose tubing of the commercial washer, with a light brown liquid dripping from it. The Infection Preventionist was unaware of the purpose of the plastic attached to the pipe. The Laundry Aide was unable to explain the condition of the commercial washer hose, and the Maintenance Director attributed the mineralization to the water softener running without salt. The Maintenance Director had not assessed the washer or the laundry area since his employment began in February. He expressed doubt about the possibility of sewage backing up in the floor sink. The Administrator acknowledged the need for a barrier between clean and dirty areas, cleaning of the washer hose, and ensuring the drainpipes are not exposed to sewage. No policies regarding laundry area maintenance or clean-dirty designation were provided by the Maintenance Director.
Pest Control Deficiency in Kitchenette
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchenette attached to the dining room, as required by their pest control policy. During an observation, fruit flies were found in a cabinet containing hot dog buns and corn tortillas, with some flies inside one of the bags of buns. The Maintenance Director, who was the sole maintenance worker, was unaware of the pest issue until it was brought to his attention during the observation. He admitted to hearing about a fruit fly problem a week prior but had not investigated it. Upon seeing the flies, he acknowledged the issue and removed the food. However, during a follow-up observation, fruit flies were still present, and the Maintenance Director recognized the need for an intervention.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted with the required details for residents, visitors, and staff. The policy mandates that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel responsible for direct care must be posted in a prominent location. This information should include the facility name, current date, resident census, shift schedule, and the type and category of nursing staff. However, an observation on September 17, 2024, revealed that the staffing information posted was outdated, showing the date as September 14, 2024, and lacked the facility name and a place to update the census for each shift. During interviews, the Administrator confirmed that the posted information was not current and acknowledged that the staff posting should be updated daily with all required elements. This oversight could potentially affect the knowledge of staff availability for the care of the 23 residents, their family members, or their representatives. The failure to post accurate and timely staffing information is a deviation from the facility's policy and could impact the understanding of staffing levels available for resident care.
Failure to Monitor and Assess Resident's Change in Condition
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice when the resident experienced a change in condition. The resident, who was severely cognitively impaired and had multiple diagnoses including vascular dementia and osteoporosis, expressed increased leg and hip pain. Despite recognizing the change in condition and ordering an x-ray, the facility failed to provide ongoing monitoring and assessment from the time the pain was reported until the x-ray results were obtained, which revealed a left hip fracture. The resident's progress notes and hospice notes indicated that pain management medications were administered, and an x-ray was ordered. However, there was no documented monitoring or assessment of the resident's condition from the time the pain was first reported until the x-ray results were reviewed. The Director of Nursing confirmed that ongoing monitoring and assessment should have been documented but were not. This lack of documentation and monitoring led to a delay in identifying the resident's hip fracture and ensuring appropriate care was provided in a timely manner.
Inadequate Pain Management and Assessment
Penalty
Summary
The facility failed to adequately assess and provide necessary care and services for a resident (R1) experiencing increased pain in the left leg and hip. Despite R1 expressing increased pain on 4/16/24, the facility did not document or reassess R1's pain levels during this period. Additionally, the care plan for R1 did not include goals regarding an acceptable level of pain or non-verbal indicators of pain, which are crucial for a resident with severe cognitive impairment and an activated power of attorney. The facility's policy on administering pain medications requires acute pain to be assessed every 30 to 60 minutes until relief is obtained, but this was not followed for R1. R1's care plan mentioned various conditions such as chronic pain, arthritis, and other ailments, but it lacked specific details on how R1 expresses pain and what non-verbal indicators to look for. The progress notes from 4/16/24 to 4/23/24 show that R1 was given scheduled and PRN pain medications, but there was no consistent documentation of pain monitoring or assessment. The facility's Director of Nursing (DON) indicated that pain is documented in progress notes and that the effectiveness of PRN pain medications is recorded, but this information was not readily accessible or consistently monitored. The facility's failure to ensure ongoing monitoring and assessment of R1's pain, especially during a change in condition, led to inadequate pain management. The DON and Nursing Home Administrator (NHA) were unaware of additional documentation regarding PRN pain medications and non-pharmacological interventions, highlighting a gap in the facility's pain management practices. This deficiency in care planning and pain assessment resulted in R1 experiencing unmanaged pain and a lack of appropriate interventions during a critical period.
Deficiencies in Food Safety Practices Identified
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety, leading to a deficiency in food safety practices. Specifically, one resident was served non-pasteurized eggs with runny yolks that were not fully cooked, putting them at risk for Salmonella infection. The facility did not have a policy regarding the use of unpasteurized eggs or safe handling procedures for shell eggs, and staff were unsure if the eggs served were pasteurized. Observations revealed that the facility had unpasteurized shelled eggs in stock, and residents were allowed to order eggs with runny yolks. Staff, including the cook and dietary aides, acknowledged serving eggs with runny yolks to residents upon request, without ensuring they were fully cooked or pasteurized. Additionally, deficiencies were noted in hand hygiene practices, as a cook was observed handling food with bare hands and not performing appropriate hand hygiene before food preparation. Further deficiencies were identified in the facility's food storage practices, as frozen food items were not properly labeled with open dates or use by dates. The facility also failed to consistently record food temperatures before placing items in hot holding, indicating lapses in monitoring and maintaining safe food temperatures. These deficiencies collectively posed a risk of foodborne illness to residents, particularly those in the highly susceptible population served by the facility.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of dust and debris buildup in resident rooms and common areas. Residents R2, R5, R6, and R1, along with a resident representative, voiced concerns about the cleanliness of their rooms. Specific observations included cobwebs, dust balls, and pieces of a broken vase in R2's room; clusters of dust under the bed and along the baseboards in R5's room; and general dust and debris throughout R6's room. R1's room was noted to have a layer of dust on the bed foot covers and dust buildup along the floorboards and behind the door. Additionally, the facility's elevator and foyer were observed to have accumulated dirt and cobwebs in the corners and along the perimeter, respectively. The facility's housekeeping checklist did not include a schedule for daily cleaning of resident rooms or a description of what deep cleaning entails. Interviews with staff revealed that housekeeping is expected to clean resident rooms daily, but the facility was down one housekeeper at the time of the survey. The facility's policy on homelike environments emphasized providing a clean, sanitary, and orderly environment, but the observations and resident reports indicated that this policy was not being effectively implemented. The lack of a clear cleaning schedule and the observed deficiencies in cleanliness contributed to the failure to maintain a homelike environment for the residents.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene. Specifically, two residents, R2 and R3, were not receiving showers as scheduled. R3, who has multiple diagnoses including muscle weakness, unsteadiness on feet, and congestive heart failure, reported not having had a shower for two months. The facility's records corroborated this, showing a lack of documentation for scheduled showers or refusals over several months. Interviews with CNAs and the Nursing Home Administrator revealed inconsistencies in documenting showers and refusals, with staff acknowledging that refusals were not always recorded as required. Similarly, R2, who has diagnoses including muscle weakness, dementia, and depression, also did not receive showers as scheduled. R2's medical records showed gaps in documentation for both given showers and refusals. Despite the care plan indicating that R2 requires moderate assistance with bathing, a CNA incorrectly stated that R2 is mostly independent. This discrepancy highlights a failure in communication and adherence to care plans. The Director of Nursing and the Nursing Home Administrator confirmed that the expectation is for staff to document all showers and refusals, which was not being consistently followed.
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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