Hebron Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 510 Genomic Drive, Madison, Wisconsin 53719
- CMS Provider Number
- 525375
- Inspections on file
- 17
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Hebron Oaks during CMS and state inspections, most recent first.
A resident with intact cognition, severe lumbar pain, and dependence on staff for toileting and bed mobility was care planned for frequent pain and required frequent incontinence care. On one shift, two CNAs attempted to provide incontinence care due to a saturated brief; the resident, who often verbally refused care because of pain and anxiety, began screaming when turned. A RN entered the room, yelled at the resident, threatened that they would be cut from therapy and kicked out if they did not cooperate, and forcibly rolled and held the resident on their side without permission while directing staff to complete incontinence care, despite the resident crying, screaming in pain, and asking to be let go. Multiple staff, including the IDON, described the RN’s behavior as bullying and verbally abusive, and the facility later substantiated that the resident was subjected to verbal and physical abuse, resulting in unnecessary pain and anxiety.
A resident with intact cognition, significant lumbar osteomyelitis, chronic pain, and dependence on staff for toileting and repositioning alleged that an RN verbally threatened discharge and forced incontinence care after the resident cried out during care. The facility’s policy required allegations of abuse or serious bodily injury to be reported to the state agency immediately, but not later than two hours after the allegation. Instead, the Administrator, who was informed of the allegation and aware that the RN had been removed from the schedule, submitted the abuse report approximately 18 hours after the event, based on his mistaken belief that non-physical abuse only needed to be reported within 24 hours, resulting in a failure to meet the policy’s required reporting timeframe.
The facility failed to enforce its abuse policy requiring immediate suspension of a staff member following an abuse allegation, allowing an RN accused of verbal and physical abuse toward a resident with significant pain, mobility limitations, and hospice care needs to return to the building on multiple occasions during the ongoing investigation. Although the RN was removed from the schedule, she was not clearly informed of her suspension, continued to clock in for work and online training, and had access to resident care areas while the allegation was being investigated. Leadership acknowledged that there was no mechanism to suspend the RN’s timecard or notify other staff of the suspension, resulting in a breakdown of protections intended to prevent further abuse.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A registered nurse was hired and began providing care without the facility completing a required out-of-state criminal background check, despite the nurse having recently lived in another state. This failure to follow the facility's abuse prevention policy resulted in noncompliance with screening procedures.
Two residents in a facility experienced inadequate pressure ulcer care, leading to the development and deterioration of pressure injuries. One resident developed three pressure injuries after admission, with insufficient wound assessments and delayed preventive measures. Another resident, admitted with a stage 4 pressure injury, experienced wound deterioration and infection due to lack of proper assessments and interventions. The facility's failure to adhere to its skin injury prevention policy resulted in immediate jeopardy for the residents.
The facility did not complete annual performance reviews for five CNAs, including two CNA/Medication Technicians, over a one-year period. The Nursing Home Administrator acknowledged the oversight, citing confusion regarding unionized CNAs as the reason for the lapse.
Abusive Verbal Threats and Forced Incontinence Care by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by a registered nurse (RN A). Facility policy on preventing abuse, neglect, misappropriation, mistreatment, and exploitation, updated 08/25/2023, states that residents will not be abused by anyone and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy clarifies that "willful" means the individual acted deliberately, even if they did not intend to inflict harm. Resident #1 was admitted on 10/02/2025 with a history of lumbar vertebral osteomyelitis, lumbar discitis, anxiety disorders, muscle weakness, and right thigh pain. An admission MDS with ARD 10/08/2025 showed intact cognition (BIMS 14), dependence on staff for toileting hygiene and rolling in bed, frequent pain that affected sleep, therapy participation, and daily activities, and a pattern of rejecting care on some days. The care plan identified chronic bilateral hip pain related to arthritis and acute back pain related to lumbar osteomyelitis, with interventions to anticipate pain needs and respond immediately to pain complaints, and to check and change the resident frequently due to ADL self-care deficits and limited mobility. On 10/09/2025, CNAs B and C attempted to provide incontinence care because the resident’s brief was saturated and there were concerns about skin breakdown. Interviews with CNAs B and C indicated that the resident was dependent for most care, incontinent of bowel and bladder, and often verbally refused care due to anxiety and significant back pain, but was not typically physically resistive. CNA C reported that the resident initially agreed to incontinence care but began screaming and asking to be put down when staff attempted to roll them. CNA B stated she left to get the IDON, who was familiar with the resident, while CNA C remained in the room talking with the resident. Both CNAs reported that RN A entered the room, yelled at the resident, and told the resident they would be kicked out of the facility and cut from therapy if they did not allow care. CNA B stated that RN A, without explanation to the resident, forcibly pulled the resident onto their side, during which the resident screamed and cried in pain and asked to be let go, while RN A continued to lecture and yell. CNA B estimated the resident was held on their side for 8–10 minutes while in pain, and then forcibly rolled to the other side so that incontinence care, ointment application, and a clean brief could be completed. CNA C corroborated that RN A ran into the room, screamed at the resident about being kicked out if they did not accept care, and rolled the resident onto their side without permission, directing CNA C to hurry and clean the resident while the IDON stood in the room observing. The IDON stated she heard the resident screaming and went to the room a couple of minutes later, where she observed RN A bullying the resident, telling them they would be kicked out of the facility and that therapy would stop if the resident did not do what RN A said. The IDON described the resident as very anxious and fearful of rolling, and recalled seeing CNAs on either side of the resident while RN A was in the resident’s face yelling. The IDON stated she left the room while staff were turning the resident but later returned to reassure the resident. An internal mistreatment/abuse report documented that RN A leaned over the resident, pointed, and stated, "I'm not going to keep doing this with you, you need to be getting out of the bed at least twice a day, and you need to knock this off or you're going to be cut from therapy and kicked out next week," while the resident was crying, upset, and in pain throughout the interaction. The facility’s Executive Director later stated that RN A should not have lectured the resident or forced incontinence care against the resident’s will, and the facility substantiated the allegation of abuse. In contrast, RN A stated in a telephone interview that the resident had bone pain from infection, was often resistant to care and to using a full-body mechanical lift, and that pain was a major issue causing the resident to cry when turned. RN A reported that a physical therapist had informed her that a care conference would be held to discuss stopping therapy due to lack of progress, and she went to the resident’s room to motivate them to participate in therapy. RN A claimed no other staff were present when she spoke with the resident, that she only reiterated what therapy had told her about possible discontinuation of therapy, and that she did not tell the resident they had to participate in therapy to stay in the facility or that they would be thrown out. RN A stated she did not recall assisting with care for the resident on that date and did not believe she had done anything wrong. However, multiple staff interviews and the internal report consistently described RN A verbally berating the resident, threatening discharge and loss of therapy, and forcibly rolling and holding the resident in painful positions against their will during incontinence care, resulting in unnecessary pain and anxiety for the resident.
Failure to Timely Report Allegation of Verbal and Physical Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe as outlined in its own Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation policy. The policy, updated on 08/25/2023, required that all allegations of abuse or serious bodily injury be reported to the Department of Quality Assurance immediately, but not later than two hours after the allegation is made. Resident #1, who had intact cognition with a BIMS score of 14, a history of lumbar osteomyelitis, discitis, anxiety disorders, muscle weakness, right thigh pain, and chronic bilateral hip and acute back pain, was dependent on staff for toileting hygiene and repositioning and experienced frequent pain that affected sleep, therapy, and daily activities. The resident’s care plan directed staff to anticipate and respond immediately to pain complaints and to check and change the resident frequently. On 10/09/2025 at 5:00 PM, an allegation of abuse occurred when RN A was observed by the Interim DON telling Resident #1, "you just need to knock it off or therapy will cut you and we will throw you out," which upset the resident. During the investigation, the Administrator learned from staff statements that RN A had forced the resident to receive incontinence care after being alerted by the resident’s crying out during care. The Administrator acknowledged being informed of the allegation on 10/09/2025 but submitted the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the state agency on 10/10/2025 at 11:00 AM, 18 hours after the allegation. The Administrator stated he believed that, because the allegation did not involve physical bodily injury, it only needed to be reported within 24 hours and admitted the initial report was not filed within two hours and that he was not aware this was required by facility policy. The Former DON stated that she and the Administrator were made aware of the incident during the morning meeting on 10/10/2025, indicating a delay in internal reporting and external notification compared to the policy’s immediate reporting requirement.
Failure to Enforce Staff Suspension After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy by not effectively suspending and excluding an alleged abuser from the premises during an ongoing abuse investigation. The facility’s written policy on abuse, neglect, misappropriation, mistreatment, and exploitation, updated on 08/25/2023, states that residents will not be abused by anyone and that the first responsibility of the facility is to assure resident safety. The policy further requires that, in the event of an allegation of abuse against a staff member, the facility must take immediate steps to ensure resident safety and prevent further harm, including at a minimum the suspension of the staff member until the investigation is complete. Despite this policy, the facility allowed the alleged abuser, a registered nurse (RN A), to re-enter and be present in the facility on multiple days after an abuse allegation was reported. Resident #1 was admitted on 10/02/2025 with a medical history that included osteomyelitis and discitis of the lumbar region, anxiety disorders, muscle weakness, and right thigh pain. An admission MDS with an ARD of 10/08/2025 showed a BIMS score of 14, indicating intact cognition, and documented that the resident rejected care on one to three days during the assessment period. The MDS also indicated the resident was dependent on staff for toileting hygiene and rolling, and experienced frequent pain that affected sleep, therapy participation, and day-to-day activities. The care plan identified chronic bilateral hip pain related to arthritis, acute back pain related to lumbar osteomyelitis, and an ADL self-care deficit related to activity intolerance, limited mobility, and hospice services, with interventions to anticipate pain needs and check and change the resident frequently. On 10/09/2025 at approximately 5:00 PM, the Interim DON observed RN A telling Resident #1, "you just need to knock it off or therapy will cut you and we will throw you out," and an abuse allegation was reported by the Administrator on 10/10/2025 at 11:00 AM. The report indicated RN A had completed her shift, left the facility, and was suspended; however, facility records showed RN A clocked in and was present in the facility on 10/11/2025, 10/12/2025, and 10/13/2025 during the ongoing investigation. Interviews revealed that RN A stated she was not informed of her suspension until 10/13/2025 while working on the 3rd floor, and that she had come in to work a shift and to complete online training and return keys. The Interim DON confirmed RN A came in the weekend after the incident to complete online training, and the Administrator stated he was unaware of RN A’s presence on 10/11/2025 and 10/12/2025 and that there was no way to suspend a staff member’s timecard or alert other staff to the suspension. As a result, the facility did not implement effective protections after the allegation of abuse involving RN A and Resident #1, allowing RN A access to residents during the investigation.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Complete Required Out-of-State Background Check for RN
Penalty
Summary
The facility failed to implement its written policies and procedures designed to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Specifically, the facility's policy requires comprehensive background checks for all employees, including out-of-state criminal background checks if the individual has resided outside of Wisconsin within the past three years. The policy outlines that such checks are necessary prior to allowing employees to work with residents. Despite these requirements, a review of a registered nurse's (RN J) employment records revealed that the facility did not obtain an out-of-state criminal background check, even though RN J had recently lived in California. The omission was confirmed during an interview with the Human Resources Business Partner, who acknowledged that the California background check was not completed before RN J began providing patient care. This failure to follow established screening procedures resulted in noncompliance with the facility's own abuse prevention policy.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development and deterioration of pressure injuries. One resident, admitted without pressure injuries, developed three pressure injuries, including two deep tissue injuries and one unstageable wound. The facility did not complete all required weekly wound assessments, and wound vacuum treatments were not properly executed. Preventive measures were not implemented until after the pressure injuries developed, resulting in wound deterioration. The resident expressed dissatisfaction with the care received, indicating a negative impact on their quality of life. Another resident was admitted with a stage 4 pressure injury and osteomyelitis. The facility failed to conduct weekly assessments and did not ensure that skin interventions were followed according to professional standards. This resident developed multiple wounds on their lower extremities, and their sacral wound deteriorated and became infected. The facility's lack of timely and appropriate interventions contributed to the worsening of the resident's condition. The facility's policy on skin injury prevention and management was not adhered to, as evidenced by the lack of prompt assessment, treatment, and monitoring of pressure injuries. The interdisciplinary care plan team did not adequately review and address risk factors for pressure injury development and healing. The facility's systemic approach to pressure injury prevention and management was insufficient, leading to immediate jeopardy for the residents involved.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least every 12 months for five Certified Nursing Assistants (CNAs) who were reviewed for in-service training. The survey team randomly selected five CNAs who had been employed at the facility for over a year, including two Certified Nursing Assistant/Medication Technicians and three Certified Nursing Assistants. Upon reviewing performance review records from February 18, 2024, to February 18, 2025, it was noted that none of these CNAs had a performance review completed during this period. The Nursing Home Administrator acknowledged the expectation for CNAs to have annual performance reviews and explained that the facility was confused about handling performance reviews for CNAs in a union, resulting in the omission of these reviews.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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