Hillside Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaver Dam, Wisconsin.
- Location
- 803 S University Ave, Beaver Dam, Wisconsin 53916
- CMS Provider Number
- 525447
- Inspections on file
- 23
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Hillside Manor during CMS and state inspections, most recent first.
A resident with Parkinson's disease, dementia, dysphagia, and essential tremor, who was care planned for feeding assistance and direct supervision, was observed eating alone in the dining room without staff seated at the table to assist or supervise. Staff present were either assisting others or unaware of the resident's specific needs, and there was no clear documentation accessible to CNAs regarding required meal assistance. The facility lacked a separate dining supervision policy, resulting in inadequate supervision during meals.
A resident with severe dementia, mood disturbance, anxiety, atrial fibrillation, and muscle weakness was not seen by a physician at the required 60-day interval after admission, as confirmed by record review and staff interviews. Facility policy requires physician visits every 30 days for the first 90 days, but the April visit and corresponding orders were missed.
Two residents' grievances, including concerns about rushed meals, improper positioning, and late meal service, were not documented or investigated according to facility policy. Staff interviews revealed a lack of understanding and adherence to the grievance process, resulting in these concerns not being tracked or resolved as required.
A resident with multiple medical conditions was found with unexplained bruising after being cared for by a CNA, and the facility did not follow its policy to interview other residents cared for by the same CNA as part of the abuse investigation. The DON confirmed that required interviews with like-residents were not conducted, resulting in an incomplete investigation.
A facility failed to provide adequate supervision and safety measures, resulting in harm to two residents and potential harm to another. One resident experienced multiple falls from a lift chair, leading to fractures and lacerations, without effective interventions being implemented. Another resident with severe cognitive impairment had 26 falls in a year, with inadequate root cause analyses and care plan interventions. A third resident was served inappropriate food for his diet level after losing his denture, posing a choking hazard. Staff were not adequately informed about interventions, and care plans were not robust enough to prevent further incidents.
The facility failed to provide meals at safe and appetizing temperatures, affecting all 52 residents. Multiple residents reported receiving cold meals, and test trays confirmed food was served in the temperature danger zone. The Associate Director of Food and Nutrition acknowledged the issue, noting that trays often sat on carts for extended periods, leading to cold food being served.
The facility failed to adhere to food safety and hand hygiene standards, affecting all 52 residents. Surveyors observed opened and undated items in refrigerators, unsealed items in freezers, and improper storage of food on the freezer floor. The meat slicer and mixer were found uncovered and unclean. Additionally, a CNA and a Dietary Aide were observed not performing hand hygiene before handling food, despite facility policies.
The facility inaccurately reported staffing data to CMS, showing no RN hours and insufficient licensed nursing coverage, despite schedules indicating otherwise. The issue was due to invalid data files, and the exact cause remains unknown.
The facility failed to maintain dignity for three residents with indwelling catheters by not covering their catheter drainage bags, as required by policy. Observations revealed uncovered bags in various settings, and interviews with staff indicated a lack of awareness and availability of dignity bags. The Director of Nursing confirmed the policy requirement for covering bags when residents are out of their rooms.
A resident with multiple diagnoses, including chronic pain and anxiety, did not have a comprehensive care plan addressing these issues. Despite being prescribed medications like fentanyl and lorazepam, the care plan lacked specific goals and interventions. The facility's policies require such plans to be developed with an interdisciplinary team, but this was not done, as confirmed by the DON during a survey.
A facility failed to ensure a licensed pharmacist conducted a monthly drug regimen review for a resident, as required by their policy. The last documented review was in September, with no review for October. The DON confirmed the absence of documentation and acknowledged the expectation for monthly completion.
A facility failed to monitor side effects for a resident on psychotropic medications, as staff were unaware of specific side effects to watch for. The resident, with a history of mood disorders, was prescribed Sertraline and Seroquel, but the care plan and records lacked documentation of side effect monitoring. Interviews with staff, including CNAs and a Med Tech, confirmed their lack of knowledge, and the DON acknowledged the expectation for monitoring, leading to a deficiency.
A resident received their medications two hours late, resulting in a 32% medication error rate. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not followed. The RN did not notify the provider of the late administration or document the actual time in the MAR.
The facility failed to properly label and store medications, as observed in two medication carts. One cart contained an expired bottle of Atropine 1% eye drops, while another had an unlabeled Combivent Respimat inhaler. The RNs acknowledged the deficiencies, and the DON confirmed the facility's policy on medication labeling and expiration.
A resident with specific dietary needs and preferences was not provided with food that accommodated their preferences, nor were they offered appealing options of similar nutritive value. Despite the facility's policy to respect patient food preferences, the resident was only offered limited options, and the staff failed to provide the always available menu for additional choices.
A resident with a history of falls experienced an unwitnessed fall, resulting in a head laceration and shoulder soreness. Despite ongoing complaints of shoulder pain, the facility's nursing staff failed to immediately consult with the on-call physician over the weekend, delaying the diagnosis of a probable distal clavicle fracture. The DON confirmed that the staff should have contacted the physician when the resident's pain increased.
Failure to Provide Required Dining Supervision and Assistance
Penalty
Summary
A deficiency occurred when a resident with significant medical needs, including Parkinson's disease with dyskinesia, dementia, dysphagia, and essential tremor, was not provided with the required level of supervision and assistance during mealtime. The resident's care plan specified the need for feeding assistance, direct supervision, and cuing due to worsening tremors and difficulty feeding independently. Despite these documented needs, the resident was observed eating alone in the dining room without staff seated at the table to provide supervision or assistance. Staff present in the dining area were either assisting other residents or unaware of the specific supervision requirements for this resident. Interviews with CNAs revealed a lack of clarity regarding which residents required meal assistance, with one CNA stating that such information would be found in computer charting, but not specifically in the CNA charting for this resident. The Assistant Director of Nursing confirmed that direct supervision meant a staff member should be seated at the table with the resident to assist with eating. The facility did not have a separate dining supervision policy and relied on care plans and general regulatory guidance, which led to inadequate supervision for the resident during meals.
Missed Physician Visit for Newly Admitted Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was seen by a physician at the required intervals following admission, as outlined in the facility's Physician Visits Policy. The policy mandates that newly admitted residents must be seen by a physician at least once every 30 days for the first 90 days, and then at least every 60 days thereafter. Record review and staff interviews confirmed that a resident with severe, unspecified dementia with mood disturbance and anxiety, as well as other medical conditions including persistent atrial fibrillation and generalized muscle weakness, was not seen by a physician in the month of April, resulting in a missed 60-day visit after admission. Both the Assistant Director of Nursing and the Interim Nursing Home Administrator acknowledged that the required physician visit and corresponding signed orders for that period were missed.
Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for two residents, as required by its own grievance policy and federal regulations. In the first instance, a resident's representative voiced concerns regarding the resident being rushed during meals and not being allowed to finish eating, as well as improper positioning on a shower chair. These concerns were communicated to facility staff but were not entered into the facility's grievance log, nor was there evidence of follow-up or investigation according to the facility's grievance process. Interviews with staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), confirmed that these concerns were not documented or tracked as grievances. In the second instance, another resident's representatives raised concerns during a meeting, which were documented in the resident's medical record and hospice notes. The concerns included late meal service, the need for assistance with menus, and the use of a different lift. Despite being documented, these concerns were not entered into the facility's grievance log, and there was no evidence that the facility's grievance process was followed. Multiple staff members, including hospice staff and registered nurses, indicated unfamiliarity with the grievance process or stated that they had never filled out a grievance form, further contributing to the lack of proper documentation and follow-up. The facility's policy requires that all grievances, whether verbal or written, be promptly recorded, investigated, and tracked through to resolution, with documentation retained for at least 18 months. However, interviews and record reviews revealed that staff were unclear about their responsibilities in reporting and documenting grievances, and that concerns voiced by residents or their representatives were not consistently handled according to policy. This resulted in grievances not being tracked, trended, or resolved in a timely manner, as required.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation in response to a potential allegation of abuse involving a resident with significant medical conditions, including osteoporosis, hemiplegia, and vascular dementia. The incident involved the discovery of discolored (yellow) areas on the resident's right knee and left ankle, which were reported by the resident's representative. The representative expressed concerns that improper positioning by a CNA during a shower may have caused the bruising and noted discomfort and unusual positioning of the resident after the bath. Despite facility policy requiring a comprehensive investigation of injuries of unknown origin, including interviews with other residents cared for by the implicated staff member, the facility did not interview other residents who had been under the care of the same CNA. The Director of Nursing confirmed that such interviews were not conducted, even though it was acknowledged that this step should have been part of the investigation process. The deficiency was identified through interviews and record review, which showed that the investigation was incomplete according to facility policy.
Inadequate Supervision and Safety Measures Lead to Resident Harm
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents, resulting in actual harm for two residents and potential harm for another. Resident 37, who has a history of multiple falls, experienced several falls from her lift chair, leading to significant injuries, including fractures and lacerations. Despite the resident's cognitive intactness, the facility did not implement effective fall interventions, and the resident continued to have control over the recliner remote, which was a known risk factor. The facility's documentation revealed repeated incidents of falls without new interventions being implemented, and staff were not adequately informed about the interventions in place. Resident 12, with severe cognitive impairment, experienced 26 falls in the past year, one of which resulted in a fracture and laceration. The facility did not conduct thorough root cause analyses for several falls and failed to ensure appropriate interventions were included in the resident's care plan. Despite the resident's repeated self-transfer attempts and poor safety awareness, the facility's interventions were ineffective, and the care plan was not robust enough to prevent further falls. The staff were not adequately informed about the interventions, and the resident's desire for independence was not effectively managed. Resident 36, who is edentulous and wears an upper denture, was served inappropriate food for his prescribed diet level after his upper denture went missing. The facility did not update the resident's diet order to reflect the new dietary needs, leading to a choking hazard when the resident was observed eating a whole banana. The dietary department was not informed of the updated diet recommendation, and the resident's meal ticket was not updated, resulting in a failure to provide the correct diet texture to prevent health and safety hazards.
Deficiency in Serving Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and at a safe and appetizing temperature. This deficiency was identified through observations, interviews, and record reviews, affecting the entire census of 52 residents. Multiple residents reported that their meals were not served at desirable temperatures, with some meals being practically cold. For instance, one resident with moderate cognitive impairment expressed that her breakfast was cold, while another resident with intact cognition stated that his food often needed to be reheated by staff. Additionally, a resident in the dining room reported that her breakfast items were cold and difficult to eat. Test trays further confirmed the deficiency, as they were observed to be served at inappropriate temperatures. During one test, a breakfast tray contained items such as a poached egg, ham slice, and hashbrowns, all of which were in the temperature danger zone. Another test tray, served later, included items like rice with tomatoes and spinach, peas, and roast pork with gravy, which were also not at the appropriate temperatures. The Associate Director of Food and Nutrition acknowledged the issue, noting that trays often sat on carts for extended periods, leading to cold food being served. Despite the expectation for food to be served at desired temperatures, this was not consistently achieved, resulting in unpalatable meals for residents.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, potentially affecting all 52 residents. During an initial tour of the kitchen, surveyors observed several deficiencies, including opened and undated items in refrigerators and coolers, such as lettuce, breadcrumbs, grapes, cucumbers, blueberries, and milk cartons. The Associate Director of Food and Nutrition (ADFN E) was unsure if these items would be used within the next 24 hours and incorrectly believed milk was good until the expiration date on the carton. Additionally, items in the freezer, such as cakes, vegetables, and meats, were found unsealed and unmarked, which ADFN E acknowledged should be properly sealed to prevent freezer burn. Boxes of food were also improperly stored on the freezer floor, and the meat slicer and mixer were found uncovered and unclean, respectively. The facility's hand hygiene practices were also found lacking. Surveyors observed a Certified Nursing Assistant (CNA T) feeding a resident without performing hand hygiene or wearing gloves. When interviewed, CNA T admitted she should have used the wipes provided on the table before assisting the resident. A Dietary Aide (DA P) was seen picking up dirty trays and dishes and then touching bread to make toast for a resident without washing hands or performing hand hygiene. Despite DA P's claim of always performing hand hygiene, two surveyors observed otherwise. These observations indicate a failure to adhere to the facility's hand hygiene policy, which aims to prevent the transmission of microorganisms via contaminated hands of healthcare workers.
Inaccurate Staffing Data Reporting to CMS
Penalty
Summary
The facility failed to ensure accurate reporting of staffing information to the Centers for Medicare & Medicaid Services (CMS) based on payroll data, which affected the facility's staffing rating and compliance. The facility's Payroll Based Journal (PBJ) reporting for fiscal year quarter 3 of 2024 showed no Registered Nurse (RN) hours and a lack of licensed nursing coverage for 24 hours a day on multiple dates. This discrepancy was noted despite the facility's staffing postings and nursing schedules indicating that there was at least 8 hours of RN coverage and 24-hour licensed nursing coverage each day. The Nurse Scheduler (NS L) and the Director of Nursing (DON B) were interviewed, revealing that the process for gathering and transmitting data had not changed for the months in question. NS L indicated that CMS was contacted when the error was noted, and it was discovered that the data file received by CMS was invalid. DON B suggested that the data might have been encrypted or sent in the wrong file type, but the exact cause of the issue was still unknown. The facility was working on processes to ensure proper reporting in the future.
Failure to Maintain Dignity for Residents with Catheters
Penalty
Summary
The facility failed to ensure that three residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and maintain their dignity. Residents were observed with their catheter drainage bags uncovered, which is against the facility's policy that promotes dignity and respect. Resident 16, who has multiple diagnoses including Parkinson's Disease and type 2 diabetes, was observed multiple times with an uncovered catheter bag, both in his room and in the hallway. Despite expressing a preference for the bag to be covered, it was often left uncovered. Interviews with CNAs revealed a lack of awareness and availability of dignity bags, contributing to the deficiency. Resident 26, admitted with a Foley catheter for wound healing, was observed with an uncovered urinary drainage bag visible from the hallway. Similarly, Resident 41, admitted with a Foley catheter for urinary retention, was observed with an uncovered drainage bag, although it was later covered during a subsequent observation. The Director of Nursing confirmed that the facility's policy requires catheter bags to be covered when residents are out of their rooms, indicating a failure to adhere to this policy consistently.
Failure to Develop Comprehensive Care Plan for Pain and Anxiety
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as R26, who was reviewed for care plans. R26's care plan did not include a problem, goal, and interventions for managing pain or anxiety, despite the resident having multiple diagnoses that necessitate such considerations. These diagnoses included major depressive disorder, chronic pain, and osteoarthritis, among others. The resident was prescribed several medications for pain management, including hydrocodone-acetaminophen and fentanyl, as well as lorazepam for anxiety. However, the care plan lacked specific and individualized instructions for staff to follow regarding these issues. The facility's policies on Psychotropic Medication Use/Chemical Restraints and Comprehensive Person-Centered Care Planning emphasize the need for care plans to be developed with the assistance of an interdisciplinary team and to include specific goals and interventions. During an interview, the Director of Nursing (DON) confirmed that residents receiving medications like fentanyl and lorazepam should have corresponding care plans addressing pain and anxiety, which R26 did not have. This oversight was identified during a survey, highlighting a deficiency in the facility's adherence to its own care planning policies.
Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for a resident, identified as R26, as required by their policy. The facility's policy mandates that a consultant pharmacist must analyze each resident's medical chart, medication administration record, and pharmacy software monthly to prevent and resolve medication-related issues. However, for the month of October 2024, there was no documentation to confirm that R26's medication regimen was reviewed by a pharmacist, despite the policy's requirement for such reviews to be completed by the end of each calendar month. During an interview, the Director of Nursing (DON B) confirmed that the reviews are typically documented in the resident's hard chart on the Medication Regimen Review form. Upon being informed of the missing documentation for October 2024, DON B acknowledged the absence of the review and stated that she would have expected it to be completed. This oversight was identified during a survey, which revealed that the last documented review for R26 occurred on September 26, 2024, with no subsequent review for the following month.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medications was free from unnecessary medications, as evidenced by the lack of monitoring for side effects of antidepressant and antipsychotic medications. The resident, who was cognitively intact and had a history of mood disorders, was prescribed Sertraline and Seroquel for depression and psychosis, respectively. However, the facility did not document any monitoring of side effects in the resident's care plan, medication administration record, or mood and behavior monitoring records. Interviews with facility staff, including CNAs and a Med Tech, revealed that they were unaware of the specific side effects to monitor for the resident's medications. The Director of Nursing acknowledged that staff were expected to monitor for side effects, but the care plan and documentation did not specify what side effects to monitor. This lack of documentation and staff awareness led to the deficiency in ensuring the resident was free from unnecessary medications.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 32% error rate during a survey. This was observed when a resident received their scheduled 8:00 AM medications at 10:02 AM, which included Systane eye drops, Senna, Vitamin C, Miralax, Calcium + Vitamin D, and Eliquis. The facility's policy requires medications to be administered within one hour before or after the scheduled time, which was not adhered to in this instance. During interviews, both the RN involved and the Director of Nursing confirmed the policy of administering medications within the specified time frame. However, the RN did not notify the resident's provider about the late administration, nor was the actual administration time documented in the Medication Administration Record (MAR), as required by the facility's policy. This oversight contributed to the high medication error rate identified during the survey.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed in two medication carts. On Swan hall, a medication cart contained an expired bottle of Atropine 1% eye drops for a resident, with an expiration date of 11/3/24. During an interview, the RN acknowledged that expired medications should not remain on the cart and subsequently removed the expired eye drops. On Monarch hall, a medication cart was found to contain a Combivent Respimat inhaler that was neither labeled nor dated, lacking a resident name or room number. The RN present during the observation was unable to identify the resident to whom the inhaler belonged, acknowledging that it should have been labeled. The Director of Nursing confirmed that medications should be dated when opened, labeled with a resident's name, and removed once expired.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences and did not offer appealing options of similar nutritive value. The resident, who has a history of dysphagia, cerebral infarction, diabetes mellitus type 2, and vascular dementia, was on a Level 6 diet according to the International Dysphagia Diet Standardization Initiative (IDDSI). Despite the resident's dietary needs and preferences, the facility did not adhere to its policy of respecting patient food preferences and making appropriate dietary substitutions. On a specific occasion, the resident was not served the menu items of their preference and was not offered appealing alternatives. The resident was only offered mashed potatoes and gravy, which they accepted, but declined shepherd's pie and was not provided with any other main meal or protein options. The Director of Nursing confirmed that staff should have offered the always available menu for additional options, which was not done in this case.
Failure to Notify Physician of Resident's Increased Pain After Fall
Penalty
Summary
The facility failed to immediately consult with a physician when there was a need to alter treatment for a resident who experienced an unwitnessed fall. The resident, who had a history of falls and was cognitively intact, fell while attempting to stand from a recliner. The fall resulted in a large laceration to the right side of the head and soreness in the right shoulder. Although the resident was transported to the emergency room for evaluation, the shoulder was not x-rayed, and the resident continued to experience pain in the shoulder in the days following the fall. Despite the resident's ongoing complaints of shoulder pain, the facility's nursing staff did not contact the on-call physician over the weekend following the fall. Instead, they sent faxes to the nurse practitioner, which did not result in immediate action. It was not until several days later that an x-ray was ordered, revealing a probable distal clavicle fracture. The Director of Nursing confirmed that the nursing staff should have called the on-call physician when the resident experienced increased pain over the weekend after the fall.
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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