Homestead Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in New Holstein, Wisconsin.
- Location
- 1712 Monroe St, New Holstein, Wisconsin 53061
- CMS Provider Number
- 525546
- Inspections on file
- 19
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Homestead Health Services during CMS and state inspections, most recent first.
A resident receiving Hospice services with multiple comorbidities, including heart failure, COVID-19, HTN, diabetes, and atrial fibrillation, experienced a significant change in condition characterized by moaning during care, increased RR, diaphoresis, lack of verbal response, low O2 saturation, and elevated blood sugar. Facility policy required immediate notification of the resident, physician, and the resident’s representative for such changes, but the activated POA, physician, and Hospice were not notified. The resident later died, and interviews with the POA, Hospice director, UM, and DON confirmed that the documented status change met criteria for a reportable change in condition that should have been communicated.
A resident with intact cognition and an activated POAHC was administered naltrexone for behavioral symptoms without prior informed consent from the resident or their representative. The DON confirmed that consent was only obtained after the medication had already been given, and the representative later revoked consent after reviewing potential side effects.
A resident with diabetes, neuropathy, and mild neurocognitive disorder did not receive gabapentin at the specific times ordered by the physician, despite clear instructions and facility policy requiring administration within a one-hour window. Multiple doses were given late, and this was confirmed by the DON and other staff during interviews.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident with moderate cognitive impairment and multiple medical conditions sustained bilateral femur fractures during a transfer when staff did not follow the care plan requiring a two-person assist with a sit-to-stand lift. The facility failed to conduct a thorough investigation, as required by policy, by not interviewing the resident about the incident or other residents to rule out further neglect by the CNA involved.
Two residents with epilepsy in an LTC facility experienced significant medication errors due to pharmacy issues and staff inaction. One resident missed doses of clobazam and Fycompa, resulting in a seizure and head injury. Another resident missed increased doses of Depakote, leading to a seizure. The facility's Medication Reconciliation policy was not effectively implemented, contributing to immediate jeopardy.
The facility's designated Infection Preventionist (IP) did not have a current certification in specialized infection prevention and control training, as required. The IP, responsible for the infection prevention and control program, confirmed that their certificate had expired. The Director of Nursing, who was supposed to oversee the program, did not monitor it. This deficiency potentially affected all 31 residents.
The facility did not adhere to its abuse policy by failing to update caregiver background checks for four CNAs within the required four-year timeframe. The CNAs were hired in 2019, but their background checks were not updated until 2024, exceeding the compliance period. The Business Office Manager confirmed the oversight after a surveyor's review.
A surveyor found that a facility failed to store drugs and biologicals according to policy in two medication storage rooms. Expired syringes and medications, as well as unlabeled and undated packages, were observed. The ADON and DON confirmed the deficiencies, noting that medications should be properly labeled and disposed of when expired.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the omission of residents with infections or conditions requiring Enhanced Barrier Precautions (EBP) from the infection surveillance line list. A resident with suspected C. diff and another with a UTI were not included in the surveillance, and EBP was not implemented for residents with chronic wounds and indwelling devices. The Infection Preventionist acknowledged these oversights, indicating a lapse in adherence to infection control policies.
A resident with severe cognitive impairment was moved to a different dining table without consulting them or their POA, violating their right to make significant life choices. The resident missed social interactions at their previous table, and the facility's policy on resident rights was not followed, leading to a deficiency.
A facility failed to ensure a resident's medical record contained a signed advance directive. The resident, admitted with dementia, diabetes, and congestive heart failure, had intact cognition but lacked a signed Power of Attorney for Healthcare (POAHC) document. The Director of Nursing was unaware of the unsigned paperwork, and the Social Services Director confirmed the oversight. The facility's admission agreement requires a complete and current copy of any advance directive, which was not obtained.
Two residents in an LTC facility did not receive prescribed seizure medications due to pharmacy issues, and their physicians and representatives were not notified as required. One resident experienced seizures, and the facility's Director of Nursing confirmed the lack of notification. Staff education was initiated to address the issue.
The facility did not provide a timely Notice of Medicare Non-Coverage (NOMNC) to three residents when their Medicare services ended. The NOMNC form, which should be delivered at least two days before the end of services, was not provided within the required timeframe. The Social Services Director confirmed the lapse in procedure.
The facility failed to report injuries of unknown origin for two residents to the State Agency. One resident had multiple injuries, including redness on the foot and bruises, which were not reported because the facility concluded no abuse occurred. Another resident had a large bruise with no known cause, and there was no documentation of a timely investigation to determine if it was reportable. The Director of Nursing did not provide documentation of an investigation, leading to a failure to report the injury.
The facility failed to thoroughly investigate injuries of unknown origin for two residents. One resident had multiple injuries attributed to a single incident without proper documentation or interviews, while another resident's large bruise was not thoroughly investigated, and a timely therapy evaluation was not conducted. The Nursing Home Administrator and Director of Nursing acknowledged the deficiencies in the investigation process.
A resident was admitted with a negative PASRR Level I Screen, but a Level II Screen was not completed after a new diagnosis and medication prescription. The resident had dementia, diabetes, and depression, and was prescribed bupropion. Interviews with the DON and SSD revealed uncertainty about PASRR requirements, leading to the deficiency.
The facility failed to provide necessary care for two residents. One resident with dementia and other health issues did not receive timely lab tests or appropriate follow-up for symptoms of weakness and painful urination. Another resident, hospitalized for heart failure, did not have daily weights recorded as ordered, impacting their care. The DON confirmed these deficiencies in care and monitoring.
A resident with dementia and epilepsy experienced a fall during a seizure, resulting in a head laceration. The facility failed to timely install anti-rollback bars on the resident's wheelchair as per the care plan, due to the bars not fitting the wheelchair. The Director of Nursing confirmed that interventions should be immediate, but the necessary equipment was unavailable, leading to a delay in addressing the fall risk.
The facility failed to provide adequate pharmaceutical services for three residents, leading to significant medication errors. A resident with severe cognitive impairment missed doses of Depakote due to a failure to send the order to the pharmacy. Another resident experienced missed doses of seizure medications due to unavailability and poor communication with the neurologist and pharmacy. A third resident refused sertraline, yet the facility continued to administer it, disregarding the resident's autonomy.
The facility failed to monitor two residents prescribed psychotropic medications. A resident on Seroquel for dementia was not monitored for side effects or effectiveness, lacking an AIMS assessment and care plan. Another resident was prescribed PRN lorazepam without a stop date, contrary to policy, and the order was not reviewed or discontinued as required. The DON confirmed these oversights.
A facility failed to provide timely lab services for a resident with C. diff. An OVA test was ordered but not completed due to a delay in sending the sample. A repeat test was ordered, but the results were not found in the medical record. The DON was unaware if the sample was sent.
The facility failed to ensure two CNAs completed the required 12 hours of in-service training, including dementia management and abuse prevention, as outlined in the Facility Assessment. Despite being responsible for monitoring training hours, the business office allowed the CNAs to continue working with residents without meeting the training requirements.
Failure to Notify POA, Physician, and Hospice of Resident’s Change in Condition
Penalty
Summary
The facility failed to notify an activated Power of Attorney for Healthcare (POAHC), the physician, and Hospice services of a significant change in condition for one resident. The facility’s policy on Change in Condition of a Resident, revised 9/20/22, required immediate notification of the resident, consultation with the physician, and notification of the resident’s representative when there is a significant change in the resident’s physical, mental, or psychosocial status. The resident involved was receiving Hospice services and had diagnoses including heart failure, COVID-19, hypertension, diabetes, and atrial fibrillation. An MDS assessment dated 9/21/25 showed a BIMS score of 14/15, indicating intact cognition, and the activated POAHC assisted the resident with medical decisions. On 9/25/25 at 5:22 AM, a progress note documented that the resident moaned during cares, had an increased respiratory rate, was diaphoretic, and was not talking. Vital signs at that time included a blood pressure of 130/51, respirations of 26, oxygen saturation of 85%, and blood sugar of 286. Despite these findings, the medical record contained no indication that the POAHC, physician, or Hospice services were notified of this change in condition. A Hospice note later documented that the resident died on 9/25/25 at 9:45 AM. During interviews, the POAHC stated they were not notified of the change in condition and were upset they were unable to be present when the resident died. The Director of Hospice Services, the Unit Manager, and the DON each confirmed that the 5:22 AM progress note reflected a change in condition that should have been reported to the POAHC, physician, and Hospice services at the time it was identified.
Failure to Obtain Informed Consent Prior to Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident or their legal representative was informed in advance of the risks and benefits of a prescribed medication, naltrexone, and did not obtain consent prior to its administration. According to the facility's policy, residents or their representatives must be informed and provide consent before initiating or increasing psychotropic medications. In this case, the resident had an activated Power of Attorney for Healthcare (POAHC), and the medical record indicated that the resident was prescribed naltrexone for sexualized behaviors. The medication was administered without documented consent or prior notification to either the resident or the representative. Interviews and record reviews revealed that the resident had intact cognition and relied on their representative to consent to medications and treatments. The Director of Nursing (DON) confirmed that consent for naltrexone was only obtained after the medication had already been administered, and that the representative later revoked consent upon learning about potential side effects. The resident expressed being upset about not being informed or consulted before receiving the medication, which was against their rights as outlined in facility policy.
Failure to Administer Medication at Prescribed Times
Penalty
Summary
The facility failed to ensure the accurate and timely administration of medication for one resident who had an order for gabapentin to be given four times daily at specific scheduled times. The resident, who had diagnoses including type 2 diabetes with neuropathy and mild neurocognitive disorder but was cognitively intact and their own decision maker, had a physician order specifying gabapentin administration at 7:30 AM, 12:00 PM, 4:00 PM, and 8:30 PM, with instructions not to give the medication early. Review of the Medication Administration Record (MAR) revealed that on multiple occasions, the medication was administered outside the one-hour window allowed by facility policy, including doses given significantly late in both the morning and evening. Interviews with the resident's family representative, the Director of Nursing (DON), and the facility's President of Success confirmed concerns about the late administration of gabapentin and verified that the medication was not given at the prescribed times on several dates. The DON acknowledged that the specific administration times were requested by the family and ordered by the physician, and confirmed that the facility policy allows a one-hour window for administration unless otherwise specified. Despite this, the medication was not administered within the required timeframe, resulting in a failure to meet the resident's pharmaceutical needs as ordered.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Investigate Potential Neglect After Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure a potential allegation of neglect was thoroughly investigated after a resident sustained bilateral femur fractures during a transfer. On the date of the incident, the resident, who had moderate cognitive impairment and multiple medical diagnoses including osteoporosis and a left artificial hip joint, was transferred from the edge of the bed using a sit-to-stand lift by a CNA. The resident's care plan at the time required a two-person assist for all transfers with a sit-to-stand lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent bilateral distal femur fractures that required surgical intervention. The incident report did not include an interview with the resident regarding the transfer or the equipment used, nor did it document the CNA's technique during the transfer. Further, the facility did not conduct interviews with other residents to determine if there were additional allegations of neglect or improper transfers involving the CNA. Both the Nursing Home Administrator and the Director of Nursing confirmed that resident interviews were not completed as part of the investigation, and the facility-reported incident documentation lacked a summary of an interview with the affected resident. This failure to follow the facility's abuse, neglect, and exploitation policy resulted in an incomplete investigation of the potential neglect.
Medication Errors Lead to Immediate Jeopardy for Residents with Epilepsy
Penalty
Summary
The facility failed to ensure that two residents with epilepsy were free from significant medication errors, leading to immediate jeopardy. One resident, diagnosed with epilepsy and dementia, was prescribed six medications for seizures, including clobazam and Fycompa. However, due to pharmacy issues, the resident did not receive clobazam for a period and missed multiple doses of Fycompa over several months. This resident experienced a seizure, fell from a wheelchair, and sustained a head laceration requiring staples. The resident reported having multiple seizures, some of which occurred when not on medication. Another resident with epilepsy, major depression, dementia, and anxiety was prescribed Depakote for seizures. The resident's bedtime dose of Depakote was increased, but the pharmacy did not receive the order, resulting in missed doses. The facility's contingency supply was exhausted, and the resident experienced a seizure. The Director of Nursing was not informed of the missed doses or the pharmacy's failure to fill the order until after the resident had a seizure. The facility's Medication Reconciliation policy was not effectively implemented, as evidenced by the failure to ensure prescribed medications were available and administered. Staff did not consistently notify the Director of Nursing or the residents' physicians and decision-makers about the unavailability of medications, leading to significant medication errors and immediate jeopardy for the residents involved.
Removal Plan
- Reviewed orders and medications on-hand to ensure medications were in-house and available to administer.
- Notified physicians, families, and residents of missing doses of medication.
- Educated staff on the facility's policy for when medication is unavailable.
- Initiated audits to ensure medications were administered as ordered.
Infection Preventionist Lacks Valid Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had a current certification in specialized infection prevention and control training, which is a requirement for long-term care facilities. The IP, identified as IP-J, was responsible for overseeing the infection prevention and control program but did not possess a valid certificate of completion for the necessary training. During the survey, the Nursing Home Administrator (NHA) was unable to provide the certificate upon request. IP-J later confirmed that the certificate had expired and was not valid. Additionally, IP-J indicated that the Director of Nursing (DON-B) was supposed to oversee the infection prevention and control program, but it was confirmed that DON-B did not monitor the program. This deficiency had the potential to affect all 31 residents residing in the facility.
Failure to Update Caregiver Background Checks
Penalty
Summary
The facility failed to implement its abuse policy by not ensuring timely completion of caregiver background checks for four Certified Nursing Assistants (CNAs). According to the facility's Abuse, Neglect, and Exploitation policy, background checks must be conducted on potential employees and re-checked in accordance with state laws and regulations. However, the facility did not complete background checks within the required four-year time frame for CNAs L, M, N, and P. These CNAs were hired on December 1, 2019, and their initial background checks were completed in November 2019, but were not updated until December 3, 2024, which is beyond the four-year requirement. During the survey, the Business Office Manager (BOM) indicated that the regional recruiter was responsible for completing background checks. Upon review, it was confirmed that the background checks for the CNAs were rerun on December 3, 2024, after the surveyor's request, confirming the original checks from November 2019 were out of compliance. This oversight in maintaining up-to-date background checks represents a failure to adhere to the facility's policy and state regulations, potentially compromising the safety and well-being of the residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with their policy in two medication storage rooms. During an observation, a surveyor found expired syringes and medications, as well as unlabeled and undated packages of ipratropium bromide and sodium chloride saline vials. Specifically, the surveyor noted four unlabeled, undated open aluminum packages of ipratropium bromide, sixty-nine unlabeled and undated pink sodium chloride saline vials not in their original packaging, nine Once Care 1 ml insulin syringes that expired on January 31, 2024, thirty Assure 1 ml syringes that expired on January 25, 2023, one bottle of B-12 vitamin 1000 micrograms that expired in September 2024, and one bottle of oyster shell with calcium 250 milligrams and vitamin D that expired in May 2024. The Assistant Director of Nursing (ADON) confirmed that the medications and supplies were opened, unlabeled, and/or expired, acknowledging that they should be in their original packaging, labeled, and disposed of appropriately when expired. The Director of Nursing (DON) also confirmed that the expired medications should have been disposed of using the Drug Buster. This oversight in medication management had the potential to affect more than four of the thirty-one residents residing in the facility.
Inadequate Infection Control and Surveillance
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of inclusion of certain residents on the infection surveillance line list and the improper implementation of Enhanced Barrier Precautions (EBP). Resident 18, who was suspected of having Clostridium difficile (C. diff), was not included on the infection surveillance line list despite being tested for the infection. Similarly, Resident 2, who was being treated for a urinary tract infection (UTI) with antibiotics, was also omitted from the surveillance list. The Infection Preventionist (IP) acknowledged missing these entries and indicated that infections are only documented and surveilled upon receiving positive test results. Additionally, the facility failed to implement EBP for residents with conditions that warranted such precautions. Resident 11, who had an indwelling urethral catheter and a stage 3 pressure ulcer, was not placed under EBP despite having chronic wounds and a history of methicillin-resistant Staphylococcus aureus (MRSA) infection. The Assistant Director of Nursing (ADON) and the IP were unsure why EBP was discontinued for this resident, acknowledging that it should have been maintained due to the resident's condition. Resident 80, diagnosed with osteomyelitis and having a peripherally inserted central catheter (PICC) line, was also not placed under EBP upon admission. The IP confirmed that EBP should have been initiated for this resident due to the presence of wounds and the PICC line. The oversight was only corrected after the surveyor's observation, indicating a lapse in the facility's adherence to its own infection control policies.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to ensure a resident's right to make choices about significant aspects of their life was respected. A resident, who had severe cognitive impairment and an activated Power of Attorney (POA) for healthcare decisions, was moved from their usual dining room table to a table where staff assisted residents with eating. This change was made without consulting the resident or their POA. The resident expressed missing the social interaction with the other residents at their previous table and their POA confirmed they were not involved in the decision-making process regarding the table change. The facility's policy on resident rights emphasizes the importance of respecting and promoting resident choices, including being fully informed about changes in care or treatment. Despite this, the Nursing Home Administrator and Director of Nursing were unsure if the resident or their POA were consulted about the move. The Director of Nursing noted that the resident's food consumption had increased since the move, but acknowledged that residents should be consulted prior to such changes. The failure to involve the resident and their POA in the decision-making process led to a deficiency in honoring the resident's right to self-determination.
Failure to Ensure Signed Advance Directive for Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident contained a signed advance directive. The resident, who was admitted with diagnoses including dementia, diabetes, and congestive heart failure, had a Minimum Data Set (MDS) assessment indicating intact cognition. Despite this, the resident's medical record included an unsigned Power of Attorney for Healthcare (POAHC) document and a signed statement of incapacity (SOI). The facility's admission agreement requires residents to provide a complete and current copy of any advance directive or other written statements regarding treatment options or designation of a healthcare agent. During the survey, the Director of Nursing (DON) was unaware that the paperwork was unsigned and indicated that the Social Services Director (SSD) would address the issue. The SSD confirmed that the paperwork was not signed and was unsure of the reason. The facility should have obtained the signature of the resident's POAHC upon admission, as per the facility's procedures. This oversight resulted in a deficiency related to the resident's right to formulate an advance directive.
Failure to Notify Physician and Representatives of Medication Issues
Penalty
Summary
The facility failed to notify the physician, guardian, and/or Power of Attorney for Healthcare (POAHC) of changes in condition for two residents, R3 and R4, out of 13 sampled residents. R3, who had diagnoses including dementia with behaviors, seizures, and anxiety, did not receive prescribed Depakote for seizures on multiple occasions. Despite having seizures and missing medication doses, R3's physician and guardian were not notified of these changes in condition as required by the facility's policy. R3's medical record showed several instances where the facility was out of Depakote, and the pharmacy was unable to provide the medication. Progress notes indicated that the facility was aware of the medication shortages, yet there was no documentation of notification to R3's physician or guardian. The Director of Nursing (DON) confirmed the lack of notification and stated that staff are expected to notify the resident's physician and representative when medication is not available. Similarly, R4, who had diagnoses including dementia and epilepsy, did not receive prescribed seizure medications due to issues with obtaining prescriptions from the pharmacy. R4's physician was only notified after multiple missed doses, and the POAHC was not informed until much later. The DON verified that staff should have notified R4's physician and POAHC when medications were missed, but documentation of such notifications was not provided. The facility began staff education to address this issue, but the deficiency was noted during the survey period.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a timely Notice of Medicare Non-Coverage (NOMNC) form to three residents, R231, R81, and R26, when their Medicare services ended. According to CMS guidelines, the NOMNC form must be delivered at least two calendar days before the end of Medicare-covered services. However, R231's Power of Attorney for Health Care signed the form a day after the services ended, R81 signed the form one day before the services ended, and R26 signed the form one day before the services ended. This indicates that the facility did not adhere to the required timeline for notifying residents about the termination of their Medicare services. The Social Services Director confirmed that residents should be notified and the NOMNC forms should be signed two days prior to the end of their Medicare services, which was not the case for the residents mentioned. This deficiency was identified through staff interviews and record reviews conducted by the surveyor.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents to the State Agency (SA) as required by their policy. Resident 3 (R3) had multiple injuries, including redness on the foot, a bump on the head, and bruises on the hand and thumb, which were not reported to the SA. The Nursing Home Administrator (NHA) indicated that these injuries were not reported because the facility concluded within the two-hour reporting window that R3 was not abused. However, the injuries developed over ten days, and R3 was on anticoagulant medication, which could cause bruises to form if R3 bumped something. Despite these findings, the facility did not report the injuries to the SA. Resident 4 (R4) had a large bruise on the chest and back, with no known cause, which was also not reported to the SA. R4 was not cognitively impaired and denied harm by staff or residents. The NHA expected staff to report such injuries if a timely investigation could not identify a cause. However, there was no documentation of an investigation being completed within two hours to determine if the injury was reportable. The Director of Nursing (DON) did not provide documentation of an investigation, leading to a failure to report the injury to the SA.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure thorough investigations of injuries of unknown origin for two residents, R3 and R4. For R3, the facility did not adequately document the steps taken to determine that multiple injuries, including a head bump, bruised left hand, and bruised left thumb, were not due to abuse or neglect. These injuries developed over a period of ten days, and the facility attributed them to an incident on 9/1/24 during care. However, there was no documentation of a root cause analysis, care plan updates, or staff education, and the investigation lacked staff and resident interviews. For R4, the facility did not conduct a thorough investigation into a large bruise that extended from the chest to the back, discovered on 8/5/24. The facility provided only an IDT note and a skin assessment as documentation. The IDT suggested the bruise might have occurred due to R4's arm rubbing against the wheelchair's metal arm, but there was no documentation of a timely therapy evaluation or a comprehensive investigation to rule out abuse. The Nursing Home Administrator acknowledged the deficiencies in the investigation process, including the lack of documentation and interviews. The Director of Nursing confirmed that R4 should have been evaluated by therapy promptly after the IDT's recommendation, but this did not occur until the week of 12/2/24, with no recommendations made. These oversights indicate a failure to adhere to the facility's policy on investigating injuries of unknown origin thoroughly.
Failure to Complete PASRR Level II Screen for Resident
Penalty
Summary
The facility failed to ensure that a resident met the Pre-Admission Screening and Resident Review (PASRR) requirements. The resident, identified as R11, was admitted with a negative PASRR Level I Screen. However, a Level II Screen was not completed when the resident received a qualifying diagnosis and was prescribed medication. The resident's medical record indicated diagnoses of dementia, diabetes, and depression, with a Minimum Data Set (MDS) assessment showing intact cognition. The resident was prescribed bupropion extended release for depression, but the necessary PASRR Level II Screen was not conducted following this change in condition. Interviews with facility staff revealed a lack of understanding and adherence to the PASRR process. The Director of Nursing (DON) and the Social Services Director (SSD) were both unsure of the requirements for completing a new PASRR when a new mental illness diagnosis or psychotropic medication was ordered. This lack of clarity and failure to follow the PASRR protocol resulted in the deficiency identified by the surveyor.
Failure to Provide Necessary Care and Monitoring for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for two residents, R17 and R11. For R17, the staff did not follow through on lab orders or complete an appropriate assessment when the resident exhibited symptoms of generalized weakness, pain with urination and pericare, and low urine output. Despite R17's symptoms and a request to see a doctor, there was a lack of follow-up after the resident was discharged from the hospital with a negative urine culture. The facility's Director of Nursing (DON) confirmed that there was incomplete follow-up on ordered tests and a failure to notify the required parties or involve the resident's physician to determine the cause of the symptoms. R17, who had diagnoses including dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, and transient ischemic attack, experienced a significant change in condition. The resident's medical record indicated multiple instances of low urine output and painful urination, yet the necessary lab tests were not completed in a timely manner. The DON acknowledged that the Interdisciplinary Team did not meet to discuss R17's symptoms, and there was no action taken to address the resident's low urine output or pain during urination and pericare. For R11, who was hospitalized for heart failure, the facility failed to consistently complete daily weights as ordered by the physician. The resident's medical record was missing several weight entries, which were crucial for monitoring the resident's condition related to heart failure. The DON confirmed that the weights should have been recorded daily and that the nurses were responsible for ensuring this was done. This oversight in monitoring R11's weight trend could have impacted the resident's care and treatment plan.
Failure to Timely Install Anti-Rollback Bars on Resident's Wheelchair
Penalty
Summary
The facility failed to ensure adequate assistive devices were in place to prevent falls for a resident, identified as R4, who had a care plan intervention to add anti-rollback bars to their wheelchair. R4, who was not cognitively impaired and had diagnoses including dementia and epilepsy, experienced a fall in the dining room during a seizure, resulting in a head laceration that required staples. Despite the care plan being updated to include anti-rollback bars on the wheelchair, the facility did not install them in a timely manner. The Maintenance Director attempted to install the anti-rollback bars but found that the bars did not fit R4's wheelchair due to its width. The Director of Nursing confirmed that care plan interventions should be implemented immediately, but the necessary equipment was not available, leading to a delay in addressing the fall risk. This inaction contributed to the deficiency as the facility did not promptly provide the required assistive device to prevent further falls.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to significant medication errors. Resident 3, who had severe cognitive impairment and a court-appointed guardian, was discharged from the hospital with an increased order of Depakote for seizures. However, the facility did not send this order to the pharmacy, resulting in missed doses and a small seizure. The Director of Nursing (DON) was unaware of the depletion of the contingency supply and the failure to send the order, indicating a lack of oversight and communication within the facility. Resident 4, who was not cognitively impaired and had a Power of Attorney for Healthcare, experienced multiple instances where prescribed seizure medications were unavailable. Despite repeated attempts by staff to contact the neurologist and pharmacy, the medications were not provided timely, leading to missed doses and reported seizures. The facility's staff documented the administration of medications that were not available, further compounding the issue. Resident 18, who had moderately impaired cognition and was their own decision-maker, refused to take prescribed sertraline for depressive symptoms. Despite this refusal and the lack of consent, the facility continued to provide the medication, as indicated in the Medication Administration Record. This action was contrary to the resident's expressed wishes and highlights a failure to respect the resident's autonomy and decision-making rights.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and documentation for two residents prescribed psychotropic medications. Resident 11, who had a diagnosis of dementia with behaviors, was prescribed Seroquel, an antipsychotic medication, but was not monitored for side effects, adverse reactions, or the effectiveness of the medication. The resident's medical record lacked an Abnormal Involuntary Movement Scale (AIMS) assessment and an antipsychotic monitoring care plan, which are required by the facility's policy. The Director of Nursing confirmed that the AIMS assessment was only completed after the surveyor's review. Resident 14, diagnosed with dementia, Alzheimer's disease, and anxiety, was prescribed lorazepam on an as-needed basis without a stop date, contrary to the facility's policy that requires PRN orders for psychotropic drugs to be limited to 14 days unless reviewed by a provider. The resident's PRN lorazepam was not administered for several months, and the order was not reviewed or discontinued as required. The Director of Nursing acknowledged the oversight in the PRN order management.
Failure to Provide Timely Lab Services for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident diagnosed with Clostridium difficile (C. diff). The resident, who had cognitive communication deficit, legal blindness, and vascular dementia with mild anxiety, had a moderately impaired cognition with a BIMS score of 12 out of 15. An order was placed on 11/1/24 for OVA and C. diff testing, but the OVA test was not completed because the sample was not sent within the required two-hour time frame. A repeat OVA test was ordered on 11/4/24, but the medical record did not contain results from this test. The Director of Nursing confirmed the order for the repeat test but was unaware if the sample was obtained and sent to the lab.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), identified as CNA-Q and CNA-R, completed the required 12 hours of in-service training during their most recent anniversary of hire year. CNA-Q, hired on January 31, 2022, only completed 2.75 hours of the required training between January 31, 2023, and January 31, 2024, and had not worked additional hours since January 31, 2024. Similarly, CNA-R, hired on July 26, 2023, completed 6.83 hours of training between July 26, 2023, and July 26, 2024, with an additional 2.75 hours completed in 2024. Both CNAs last worked on August 15, 2024. The Nursing Home Administrator (NHA) confirmed that the facility's business office was responsible for monitoring CNA hours to ensure compliance with the 12-hour training requirement. Despite this, CNA-Q and CNA-R continued to work with residents without completing the necessary training. The facility's Facility Assessment, dated September 3, 2024, outlined the requirement for in-service training to include dementia management and resident abuse prevention, among other competencies. However, the facility did not adhere to these requirements, resulting in a deficiency noted by the surveyor.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
