Ingleside Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Horeb, Wisconsin.
- Location
- 407 N Eighth St, Mount Horeb, Wisconsin 53572
- CMS Provider Number
- 525331
- Inspections on file
- 27
- Latest survey
- October 13, 2025
- Citations (last 12 mo.)
- 61 (3 serious)
Citation history
Health deficiencies cited at Ingleside Manor during CMS and state inspections, most recent first.
A resident with multiple comorbidities was admitted with an abdominal wound that was not comprehensively assessed according to professional standards. Initial and ongoing wound assessments were incomplete, lacking documentation of key characteristics such as drainage, odor, and changes in size. Despite the wound increasing in size and developing a foul odor, there was no timely physician notification. The resident's condition worsened, leading to hospital readmission with a wound infection and septic shock.
Multiple residents reported and were observed to have unclean rooms, including visible debris, dried spills, and fecal matter, with staff confirming that housekeeping was not performed regularly due to staffing shortages. Facility policy requiring regular cleaning was not consistently followed, and there was insufficient communication with residents about their housekeeping concerns.
Multiple residents did not receive medications as ordered due to issues such as internet outages, medication unavailability, and untimely administration by nursing staff. Facility policies requiring timely medication administration and error reporting were not consistently followed, resulting in missed and delayed doses for residents with complex medical needs.
A resident with multiple chronic conditions was not consistently allowed to eat in the dining room as per her documented preference, due to staff failing to coordinate her morning care and shower schedule. Despite her care plan and meal tickets indicating her choice, she was served breakfast in her room instead of the dining room, which was confirmed by interviews with the CNA, DM, and DON.
A resident with a stage 2 pressure injury and multiple comorbidities did not receive prescribed pressure ulcer prevention interventions, including use of a pulsating mattress, pressure-relieving cushion, and regular repositioning. Staff failed to ensure these interventions were in place, and the care guidance provided to CNAs did not include necessary pressure injury prevention measures.
A resident with a suprapubic catheter was observed with their catheter tubing and drainage bag resting on the floor, contrary to facility policy and care plan instructions. Both a CNA and the DON confirmed that catheter equipment should not be on the floor, and the resident expressed concern due to a history of UTIs.
The facility did not develop or implement care plans for two residents with significant behavioral health needs—one with a substance use disorder and another with a history of suicidal ideation and attempts. Staff failed to assess, monitor, or provide interventions for these conditions, and the facility lacked a substance abuse policy. Key staff were unaware of the residents' behavioral health issues, and no referrals or precautions were put in place.
Two residents did not receive critical prescribed medications, including seizure medications and insulin, due to issues such as internet outages and unavailable drugs. Facility staff did not follow established policies for medication administration, failed to use available contingency supplies, and did not effectively communicate alternative procedures, resulting in significant medication errors.
Multiple residents reported and were observed to be affected by flies and ants in their rooms and common areas, with flies landing on a resident during an interview and others using fly swatters or sticky strips to manage the issue. Despite the facility's pest control policy, staff and maintenance acknowledged ongoing pest problems and could not confirm an effective plan to address the infestation.
A resident with type 2 diabetes had blood glucose readings above the ordered threshold on two occasions, but the physician was not immediately notified as required by orders and facility policy. Nursing staff and the DON confirmed that notification and documentation should have occurred at the time of the events, but records showed no timely communication with the provider.
An LPN suspected that a nurse may have taken medication from the med cart after accessing it without proper oversight, but did not immediately report this suspicion to the DON or NHA as required by facility policy. The LPN acknowledged knowing the reporting requirement but failed to act, and the NHA confirmed that no report was made.
A resident with impaired mobility due to osteoarthritis did not receive or have documentation for the required number of showers, as only a fraction of scheduled showers were recorded. Facility staff confirmed that showers were to be documented and that missing documentation meant the care was not provided, resulting in a failure to meet the resident's needs for personal hygiene and skin assessment.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
A resident with multiple medical conditions and moderate cognitive impairment was not seen by a physician within the required timeframe after admission, as only a nurse practitioner visit was documented. The DON confirmed that the resident did not receive the mandated physician visits according to facility policy and federal regulations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
Staff failed to follow infection control protocols during wound care and perineal care for two residents. An LPN did not perform hand hygiene between glove changes while treating a resident with lower limb wounds, and a CNA placed used washcloths and a towel inappropriately after pericare, contaminating clean areas. Both incidents were acknowledged by staff as breaches of the facility's infection prevention policies.
The facility failed to provide adequate supervision and implement required safety interventions for several residents, including one who eloped without staff knowledge, two who smoked without proper assessments or care plans, one who voiced suicidal ideations without appropriate follow-up, and another at risk for falls without documented interventions. These deficiencies were identified through observations, interviews, and record reviews, revealing lapses in assessment, care planning, and staff communication.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not adequately meet the individual's nutritional and hydration needs.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices. The report does not specify the actions or omissions that led to this deficiency or provide details about the individuals involved.
The facility did not complete annual performance evaluations for all CNAs and failed to provide the required 12 hours of annual in-service education for several staff, as confirmed by record review and administrator interviews. Documentation showed incomplete evaluations and insufficient education hours for multiple CNAs, with no specific policy in place for in-service education.
The facility did not ensure its QAA Committee included all required members, such as the Medical Director, and failed to meet at least quarterly as mandated. Sign-in sheets and administrator interviews confirmed these lapses, potentially affecting all residents.
The facility did not report several incidents, including a resident elopement and two resident-to-resident altercations, to the State Agency as required. Staff interviews revealed inconsistent training and understanding of reporting procedures for abuse, neglect, and altercations.
Staff interviews revealed inconsistent training on handling resident-to-resident altercations. While a CNA reported receiving training on deescalation and reporting, an LPN stated she had not received such training. An RN indicated prior training and referenced posted materials and communication tools for tracking incidents. The administrator confirmed the need for thorough investigation of all alleged violations.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided as required.
The facility did not maintain complete and accurate medical records for several residents, including missing documentation of a resident's change in condition and death, lack of nursing follow-up after a resident expressed suicidal ideation, and failure to document a resident-to-resident altercation in both involved residents' records. These actions did not meet facility policy or professional standards for medical recordkeeping.
A resident with impaired mobility and no cognitive impairment fell and struck her head when a Hoyer lift sling ripped during a transfer performed by a CNA and the DON. The sling used had been brought with the resident from the hospital. The incident was not documented in the EMR, and staff were unsure if an incident report was completed, despite facility policy requiring safe transfer techniques and proper documentation.
A resident experienced a significant change in eating habits, which was not promptly communicated to hospice or her family. Despite facility policies requiring notification of such changes, staff failed to inform the appropriate parties in a timely manner. The resident, who had diagnoses including senile degeneration of the brain and was utilizing hospice services, was eventually sent to the emergency room after hospice was notified several days later.
A facility failed to report a resident-to-resident abuse allegation within the required two-hour timeframe. The incident involved two residents, one with metabolic encephalopathy and the other with dementia and anxiety. The abuse was reported by a family member via email, leading to a delay in notifying the administration and the State Agency. Staff members were informed of the incident on the night it occurred and reported it to the nurse, but the administration was not aware until the next day.
A facility failed to thoroughly investigate a resident-to-resident abuse allegation involving two residents with cognitive impairments. The investigation did not include interviews with staff on duty during the incident, and inconsistencies were found in the information gathered. The Assistant Administrator acknowledged the investigation's shortcomings, leading to a deficiency.
A resident experienced late or missed medication administrations, contrary to the facility's policy requiring medications to be given within one hour of the prescribed time. The resident, with conditions including pulmonary hypertension and hypertension, reported receiving medications late and occasionally not at all, leading to chest pain and the need for nitroglycerin. The DON confirmed the late administrations.
The facility failed to maintain a medication error rate below 5%, with surveyors observing a 64.28% error rate. Three residents received their medications more than an hour late, contrary to facility policy. Delays were due to staff being new, behind schedule, or pulled to other tasks. Staff interviews revealed issues with pharmacy delays and lack of access to contingency supplies, impacting timely medication administration.
A resident with a history of heart failure experienced a significant change in condition, including weight gain and increased fatigue, which was not properly assessed or reported by the facility staff. Despite symptoms such as elevated heart rate and increased oxygen needs, the physician was not notified in a timely manner, resulting in the resident's hospitalization for atrial flutter and acute decompensated heart failure.
The facility failed to properly clean and disinfect the ice machine, potentially affecting all 56 residents. A surveyor observed a black film on the ice machine lid, and staff were unclear about cleaning responsibilities. The Maintenance Director admitted to cleaning the machine randomly, without a set schedule, despite the facility's policy requiring regular cleaning.
The facility failed to properly dispose of garbage, leading to unsanitary conditions around the main dumpster. Observations revealed waste such as used gloves, food waste, and stagnant water scattered on the ground. Interviews with staff, including the Dietary Manager and Maintenance Director, highlighted unclear responsibilities and inconsistent enforcement of cleanliness around the dumpster area.
The facility failed to establish a comprehensive infection prevention and control program, affecting all residents. The ADON/IP confirmed that only COVID-19 cases are tracked among staff, lacking a comprehensive line list for other infections. Additionally, infection control policies have not been updated annually, with some policies not revised since 2022 and 2023.
The facility failed to ensure that residents had access to call lights or a means to call staff for assistance. Four residents, including those with cognitive impairments and mobility issues, were observed or reported having call lights out of reach, leading to difficulties in obtaining staff assistance. The Nursing Home Administrator acknowledged the expectation for call lights to be accessible, highlighting a deficiency in meeting residents' needs.
The facility failed to maintain appropriate water temperatures, affecting several residents who reported cold water during showers and in bathroom sinks. Despite staff efforts to address the issue, the problem persisted, with some staff unaware or not reporting it to maintenance. This deficiency impacted residents' comfort and highlighted communication gaps within the facility.
The facility failed to notify physicians promptly about critical changes for two residents. One resident had a positive urine culture, but the provider was not informed, delaying treatment. Another resident missed nighttime medications, and the primary physician was not notified. The facility's policy requires immediate physician notification for abnormal lab results and missed medications, but this was not followed.
A facility failed to develop a comprehensive care plan for a resident on Eliquis, an anticoagulant, omitting necessary monitoring for side effects like bruising or bleeding. Despite the resident's severe cognitive impairment and history of falls, the care plan did not reflect the anticoagulant therapy or required monitoring. Staff interviews confirmed awareness of monitoring needs, but these were not documented in the care plan or medication records.
A resident at risk for pressure injuries developed a wound due to the facility's failure to implement a repositioning plan. Despite being dependent on staff for repositioning, the resident was not regularly repositioned unless assistance was requested. The wound was attributed to urinary catheter tubing under the resident's leg while in a recliner, highlighting inadequate preventive measures.
A resident at risk for malnutrition experienced significant weight loss due to inadequate monitoring of meal intake and inconsistent documentation. Despite being on a low fiber diet with specific dietary instructions, the resident's meal intake was poorly documented, with only 20 meals charted out of 246 over 82 days. Communication gaps and unclear responsibilities among staff contributed to the oversight of the resident's nutritional needs.
A resident with multiple health conditions did not receive their scheduled nighttime medications due to incomplete documentation of vital signs by the PM shift. The RN discovered the issue but did not verify if the medications were given, and the DON was unaware of the error. The facility failed to ensure medications were administered on time as per physician orders.
A facility failed to ensure that a resident's care plan included targeted behaviors to monitor the effectiveness of psychotropic medications. The resident was prescribed Bupropion, Quetiapine, and Sertraline, but the care plan lacked specific behavior monitoring. Interviews with staff revealed a lack of training and clarity on individualized behavior monitoring, and the facility's electronic medical record system did not update care plans with specific behaviors. This resulted in a generalized approach to monitoring, preventing adequate assessment of medication effectiveness.
A facility experienced an 8% medication error rate when an RN failed to administer medications according to physician orders. A resident with Peripheral Vascular Disease and Hypertension received incorrect doses of Hydrocortisone and Carvedilol, with the latter given without a meal and outside the prescribed time frame. The ADON confirmed these errors, highlighting the need for proper medication handling.
Two residents in a LTC facility experienced significant medication errors. One resident received Midodrine despite having a systolic blood pressure above the prescribed limit, resulting in multiple errors. Another resident did not receive nighttime medications, including insulin, as the medications were not signed out. The facility's policy requires medications to be administered safely and timely, but these incidents show a failure to adhere to prescribed parameters and timely administration.
A resident with chronic respiratory conditions was not offered a follow-up pneumococcal vaccine after becoming eligible, despite CDC recommendations. The facility's process for tracking vaccine eligibility, which involved checking the Wisconsin Immunization Registry every few months, failed to ensure timely vaccination.
Failure to Complete Comprehensive Wound Assessments and Timely Physician Notification
Penalty
Summary
A resident was admitted to the facility with a wound on her left abdomen, along with other medical conditions including rheumatoid arthritis, type 2 diabetes with polyneuropathy, and heart failure. Upon admission, the wound was noted to have exudate and odor, but the initial assessment was performed by an LPN, which is not in accordance with the Wisconsin Nurse Practice Act that requires an RN to conduct assessments. There was no evidence that an RN reviewed or signed off on the LPN's observation, nor was there documentation that a provider was notified about the wound odor at that time. Throughout the resident's stay, the facility failed to complete ongoing comprehensive wound assessments as required by professional standards and facility policy. Documentation was inconsistent and incomplete, lacking critical wound characteristics such as type, bed description, surrounding tissue appearance, drainage, and odor. The wound increased in size and developed a foul odor, but there was no timely notification to the physician regarding these changes. Multiple staff interviews confirmed that changes such as increased wound size, odor, and drainage should have prompted provider notification, but this did not occur. The resident's condition deteriorated, with the wound developing thick, green/brown drainage, increased pain, and redness. Eventually, the resident requested to be sent to the emergency department, where she was diagnosed with a wound infection and septic shock. Hospital records confirmed the presence of multiple organisms in the wound culture. The lack of comprehensive wound assessment, failure to follow professional standards, and delayed physician notification directly contributed to the resident's readmission to the hospital with a serious wound infection.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations and resident interviews. Several rooms were found to be unclean, with one resident's room containing dried substances, crumbs, and what staff identified as fecal matter on the outside of the toilet that had reportedly been present for over a month. Additional observations included trash bags containing dirty linen and personal protective equipment left on the floor, and floors with visible debris and dried spills. Residents reported that housekeeping did not clean their rooms regularly, with some stating their rooms were cleaned only once a week or less frequently. Staff interviews confirmed the lack of regular cleaning, with a CNA acknowledging that not all rooms could be cleaned daily and the Housekeeping Supervisor citing insufficient staffing to complete all necessary cleaning tasks. The facility's own policy required regular cleaning and disinfection of resident rooms, but this was not consistently followed. There was also a lack of systematic communication with residents regarding their housekeeping concerns, as the Housekeeping Supervisor did not participate in resident council meetings to address such issues.
Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of multiple residents, resulting in missed, delayed, or omitted medication doses. For several residents, medications were not administered as ordered due to various reasons, including the facility's internet being down, medications being unavailable, and untimely administration by nursing staff. Facility policies required medications to be administered in a safe and timely manner, within one hour of the prescribed time, and for medication errors to be documented and reported. However, these policies were not consistently followed. One resident with multiple sclerosis, convulsions, major depressive disorder, and vitamin D deficiency did not receive scheduled medications at two different times because the facility's internet was down, and staff did not utilize available contingency plans such as printed MARs or alternative internet access. Another resident with rhabdomyolysis and traumatic ischemia of muscle also missed a scheduled dose for the same reason. Interviews with the DON and ADON confirmed that these omissions were considered medication errors and that staff were not fully aware of or did not implement alternative procedures during the internet outage. Additional deficiencies included a resident with metabolic encephalopathy, sepsis, diabetes, epilepsy, and other conditions who missed multiple doses of critical medications over several days due to drug unavailability, despite the facility having a contingency supply. Another resident with end stage renal disease and epilepsy did not receive several medications after returning from a hospital stay because orders were not promptly renewed and medications were not available for an extended period. Furthermore, a resident reported regularly receiving medications late, and review of MARs and staff interviews confirmed that morning medications were administered well outside the required time frame, constituting medication errors. These events demonstrate failures in medication acquisition, timely administration, and adherence to facility policy.
Failure to Honor Resident's Dining Location Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's stated preference to eat meals in the dining room, as required by both facility policy and federal regulations regarding resident rights. The resident, who has a history of multiple sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, expressed her desire to eat in the dining room for social interaction and because she had no suitable place to eat in her room. Despite her care plan and meal tickets indicating her preference for dining room meals, staff did not consistently facilitate this choice. On the morning in question, the resident was not taken to the dining room for breakfast due to a delay in her scheduled shower, resulting in her receiving her meal in her room instead. Interviews with facility staff, including the CNA, Dietary Manager, and DON, confirmed that the resident's preference to eat in the dining room was known and documented. The DON acknowledged that it is the resident's right to choose where to eat and that staff should honor this choice. However, the failure to coordinate care and ensure the resident was clean and dressed in time for breakfast led to her not being able to exercise her right to dine in the dining room as she wished.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Multiple Sclerosis, cerebral infarction, major depressive disorder, muscle weakness, and heart failure, was not provided with appropriate pressure ulcer prevention and care as outlined in facility policy and physician orders. The resident, identified as being at risk for pressure injuries, had a stage 2 pressure injury to the coccyx. The care plan and physician orders specified the use of a pulsating mattress, a pressure offloading cushion when up in a chair, and repositioning every 30 minutes. However, during the survey, the resident was observed sitting in a recliner without a cushion, and the specialty mattress was set to static rather than pulsate. Staff did not encourage or assist the resident to reposition during the nearly hour-long observation period. Further review revealed that the Resident Profile sheet used by CNAs to guide care did not include any pressure injury prevention interventions, despite these being present in the care plan and physician orders. Interviews with CNAs and the DON confirmed that the necessary interventions were not being followed, and the DON acknowledged that the resident's pressure injury prevention devices were not in place as required. The lack of implementation and communication of pressure injury prevention measures directly contributed to the deficiency.
Catheter Bag Placement Deficiency
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter was observed with their catheter tubing and drainage bag resting on the floor while seated in a recliner. The resident expressed concern about the care of their catheter tubing and drainage bag, noting a history of urinary tract infections. Facility policy, physician orders, and the resident's care plan all specify that catheter tubing and drainage bags should not touch the floor to prevent infection. During interviews, both a CNA and the Director of Nursing confirmed that catheter tubing and drainage bags should not be placed on the floor, and acknowledged that the observed situation was not in accordance with facility protocols. The deficiency was based on direct observation, resident interview, and review of relevant documentation, all of which indicated that the required standard of care for catheter management was not maintained for this resident.
Failure to Provide Behavioral Health Care and Services for Residents with SUD and Suicidal History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to ensure residents received the highest practicable mental and psychosocial well-being. Specifically, the facility did not create comprehensive assessments or care plans to address a substance use disorder (SUD) for one resident and failed to address a history of suicidal ideations and attempts for another resident. The surveyor found that the facility did not have a substance abuse policy, and the care plans for both residents lacked goals, interventions, and monitoring related to their behavioral health needs. One resident with a documented SUD, including alcohol and cocaine abuse, was admitted with multiple related diagnoses such as alcohol-induced chronic pancreatitis and end-stage renal disease. Despite evidence of ongoing alcohol consumption, including the discovery of empty vodka bottles in the resident's room and a missed dialysis session, the facility did not develop or implement a care plan addressing the resident's substance use, triggers, or associated behaviors. The social worker was unaware of the resident's SUD and no referral to the facility's substance use program was made, as referrals were only initiated with a physician or NP order, not based on active diagnoses. Another resident with a history of conversion disorder, PTSD, personality disorder, and multiple suicide attempts was not provided with a care plan addressing suicidal ideations or attempts. The care plan did not include any goals, interventions, or monitoring for suicide risk, despite the resident's extensive history of attempts, including recent overdoses and self-harm. Staff interviews confirmed that such histories should be care planned to inform monitoring and interventions, but this was not done, and no precautions or monitoring were in place for the resident's behavioral health needs.
Failure to Prevent Significant Medication Errors Due to System and Supply Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two residents not receiving their prescribed medications as ordered. For one resident with a diagnosis of unspecified convulsions and a risk for seizures, two critical seizure medications, Lamictal and Levetiracetam, were not administered as scheduled due to the facility's internet being down. Documentation on the Medication Administration Record (MAR) indicated the medications were not given, with the reason cited as 'no internet.' Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that missing a medication dose for this reason is considered a medication error, and that alternative methods for accessing the MAR, such as making paper copies or using management's cell phone hotspots, were not effectively communicated or implemented at the time of the incident. Another resident, admitted with multiple complex diagnoses including metabolic encephalopathy, sepsis, acute respiratory failure, type 2 diabetes, epilepsy, hypertension, kidney transplant status, and hypothyroidism, did not receive several ordered medications over multiple days. These included anticonvulsants (Lacosamide and Levetiracetam), insulin, and an immunosuppressant (Mycophenolate). The MAR showed multiple instances where medications were not administered, with reasons such as 'drug/item unavailable' or left blank, indicating omission. The DON confirmed that these omissions were medication errors and that staff should have accessed contingency medication supplies, which were available for at least some of the missed medications. Facility policies required medications to be administered in accordance with prescriber orders and within specified timeframes, and mandated that medication errors be documented and reported. The events described show that these policies were not followed, resulting in significant medication errors for both residents. The failures included lack of timely administration, inadequate communication of contingency procedures, and failure to utilize available medication supplies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of flies and ants in multiple areas, including the dining area, hallways, and resident rooms. Observations included flies landing on a resident's leg and foot during an interview, as well as reports from several residents about persistent fly infestations in their rooms and throughout the facility. Some residents reported that flies landed on their food during mealtimes, and others mentioned having to use fly swatters or sticky strips to manage the problem themselves. Ant strips covered with ants were also observed in one resident's room. Residents with varying degrees of cognitive impairment and intact cognition voiced concerns about the ongoing pest issues, with some stating they had reported the problem to staff but had not seen any improvement. Maintenance staff acknowledged awareness of the fly problem and indicated that pest control services were provided on a scheduled basis, but could not confirm any specific plan in place to address the current infestation. Facility records and staff interviews confirmed that the pest control program was not effectively implemented to prevent or address the presence of pests as required by policy.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify and consult with a resident's physician after significant changes in the resident's condition. Specifically, a resident with type 2 diabetes mellitus had blood glucose readings above the ordered parameter of 350 on two occasions. The physician's orders clearly stated that if blood sugar was greater than 350, the nurse should administer 5 units of insulin and call the medical doctor. Despite this, there was no documentation in the resident's progress notes indicating that the physician had been contacted regarding these elevated blood sugar levels. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the physician to be notified and for this notification to be charted each time the blood sugar exceeded the specified threshold. Review of the resident's records showed no such documentation at the time of the events. A late entry was made the following day, indicating that the provider was informed of the previous day's elevated readings, but this was not done immediately as required by the physician's orders and facility policy.
Failure to Immediately Report Suspected Misappropriation of Medication
Penalty
Summary
A deficiency occurred when an LPN failed to immediately report a suspicion of misappropriation of medication as required by facility policy and state law. The incident began when a Registered Nurse/Infection Preventionist (RN/IP) requested and took the keys to the medication cart from the LPN, accessed the cart, and later stated they had found what they were looking for. The LPN, suspecting that medication may have been taken, performed a count of the narcotic medications and found the count to be correct, but noted that there was no way to verify the count of other medications. Despite suspecting possible misappropriation, the LPN did not report the concern to the Nursing Home Administrator (NHA) or Director of Nursing (DON) as required by facility policy. During interviews, the LPN acknowledged awareness of the requirement to report suspicions of misappropriation to the DON or NHA but admitted not doing so. The NHA confirmed that staff are expected to immediately report such suspicions and that no report had been made by the LPN regarding this incident. Facility policies reviewed by the surveyor clearly state that any suspicion of misappropriation must be reported immediately to the administrator and appropriate authorities for investigation.
Failure to Provide and Document Required Showering Assistance
Penalty
Summary
The facility failed to provide and document regular showering assistance for a resident who required help with activities of daily living due to impaired mobility from osteoarthritis. According to the facility's own policy, showers are to be given to promote cleanliness, comfort, and to observe skin condition, with specific documentation required for each shower, including date, time, staff involved, skin assessment, and resident tolerance. The resident was scheduled to receive showers twice weekly, but only six showers were documented over a period in which 23 should have occurred. Interviews with the DON, medical records staff, and a CNA confirmed that showers were to be documented on paper forms and uploaded into the electronic medical record. However, there were significant gaps in the documentation, and the DON acknowledged that if a shower was not documented, it was considered not done. The lack of documentation and the inability to provide records for the majority of scheduled showers indicated that the facility did not consistently provide or record the required showering assistance for the resident.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Physician Visits After Admission
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. According to facility policy and OBRA regulations, a resident must be seen by a physician within 30 days of admission, then at least every 30 days for the first 90 days, and every 60 days thereafter. Record review and staff interview revealed that a resident admitted with diagnoses including cellulitis of the left lower limb, chronic venous insufficiency, and edema, and with moderate cognitive impairment, was only seen by a nurse practitioner shortly after admission. There was no documentation that the resident was seen by a physician within the required 30-day period after admission. During an interview, the DON confirmed that the only documented visit for the resident since admission was by a nurse practitioner, and acknowledged that the resident had not been seen by a physician as required by policy and regulation. This failure to ensure timely physician visits was identified through both record review and staff interview.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Infection Control Protocols During Wound and Perineal Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by staff not adhering to established hand hygiene and perineal care protocols for two residents. During wound care for a resident with cellulitis, venous insufficiency, and edema, an LPN removed gloves five times and applied new gloves without performing hand hygiene between glove changes, contrary to facility policy and standard infection control practices. Both the LPN and the Director of Nursing acknowledged that hand hygiene should have been performed after glove removal and before donning new gloves, but it was not done during the observed procedure. In a separate incident, a CNA performing perineal care for another resident used two washcloths for cleaning and rinsing, then placed the used washcloths back into the wash basin and the used hand towel onto the resident's bedside table next to personal items. The CNA confirmed that these items were contaminated after use and should not have been placed back into the basin or on the bedside table. The facility's infection preventionist also confirmed that contaminated items should not be returned to clean areas or surfaces, indicating a breach in infection control practices during perineal care.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for multiple residents, resulting in deficiencies related to accident hazards and resident safety. One resident, who was identified as an elopement risk upon admission and had a history of wandering, was not provided with necessary interventions such as a Wanderguard or increased supervision. This resident was able to leave the facility unnoticed and was found walking down a busy street by a staff member on break. There was no documentation of a full assessment, vital signs, or follow-up monitoring after the resident was returned to the facility. Two residents who were identified as smokers did not have smoking assessments or care plans in place, despite facility policy requiring such evaluations upon admission. Staff interviews confirmed that smoking assessments and care plans were expected but not completed. Both residents were observed smoking on multiple occasions, and staff described informal processes for supervising smoking, but there was no formal documentation or individualized planning to address their safety needs related to smoking. Another resident who voiced suicidal ideations did not have a trauma assessment or care plan for suicidal ideations, and there was no documentation of notification to the DON, provider, or family. Staff interviews revealed inconsistent understanding of the required procedures following suicidal statements, and the resident was placed on 1:1 supervision without clear documentation or follow-up. Additionally, a resident at risk for falls did not have fall interventions in place, and fall interventions were not present on CNA care cards or the resident's Kardex, despite being listed in the care plan. Staff were unclear about the current fall interventions, and there was a lack of consistent documentation and implementation of fall prevention measures.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, were not provided in the report. No further information about the circumstances or individuals affected was included.
Failure to Complete Annual CNA Evaluations and Required In-Service Education
Penalty
Summary
The facility failed to complete annual performance evaluations for all nurse aides and did not provide the required 12 hours of annual in-service education for several staff members. Record review showed that none of the five nurse aides selected for evaluation had performance reviews completed every 12 months as required by facility policy. Additionally, four out of five nurse aides did not complete the mandated 12 hours of continuing education within the year, with documented hours ranging from 8.5 to 10 out of the required 12. The facility also lacked a specific policy or procedure addressing the required in-service education for nurse aides. Interviews with the Nursing Home Administrator confirmed that the required annual evaluations and education hours were not completed for the staff in question. The administrator acknowledged that each CNA should have a current evaluation and at least 12 hours of annual education, but records did not support compliance with these requirements. The deficiency was identified through both record review and staff interviews, with specific examples cited for each staff member involved.
Failure to Maintain Required QAA Committee Membership and Meeting Frequency
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required membership and meeting frequency as outlined in its own policy and federal regulations. Specifically, the QAA Committee did not consistently include the Medical Director, who is a required member, during meetings held in June 2024 and July 2025. Additionally, the committee did not meet at least quarterly as required, with two meetings over the last four quarters not occurring within the appropriate timeframe. Review of sign-in sheets confirmed the absence of the Medical Director at the specified meetings, and there was no documentation to support that the Medical Director was informed of the meeting content in a manner consistent with policy requirements. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging both the absence of the Medical Director at the required meetings and the failure to meet the quarterly meeting schedule. The facility's QAPI policy specifies the necessary committee members and meeting frequency, but records and interviews demonstrated that these requirements were not met. This deficiency has the potential to affect all 48 residents residing in the facility.
Failure to Timely Report Abuse, Neglect, and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported to the appropriate authorities within the required timeframes. Specifically, three out of five reportable incidents were not reported as mandated. One resident eloped from the facility, and two separate resident-to-resident altercations occurred, but none of these incidents were reported to the State Agency as required by regulations. Interviews with staff revealed inconsistencies in training and knowledge regarding the reporting and management of resident-to-resident altercations. While a CNA indicated awareness of the need to deescalate and report such incidents immediately, an LPN stated she had not received recent training on this topic. An RN reported having received training and posted relevant materials at a nurses' station, but also noted that further education was planned. These findings indicate that the facility did not consistently follow established procedures for timely reporting of incidents involving potential abuse or neglect.
Inconsistent Staff Training on Resident-to-Resident Altercations
Penalty
Summary
Surveyor interviews revealed inconsistent staff training regarding resident-to-resident altercations. A CNA reported having received training on deescalating and reporting such incidents, while an LPN stated she had not received any recent training on this topic. The LPN described her intended response to future altercations, which included separating residents and redirecting them, but this was not based on formal training. An RN indicated she had received training in the previous months and referenced a flow sheet on resident altercations posted at a nurses station, as well as the use of a 24-hour board to communicate resident behaviors and incidents between shifts. The Nursing Home Administrator confirmed that all alleged violations should be thoroughly investigated.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and agreed to by the resident, and that proper care was given to those with feeding tubes.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for multiple residents, as required by facility policy and professional standards. For one resident with Alzheimer's disease, seizures, and intellectual disabilities, there was no documentation in the medical record regarding a significant change in condition and subsequent death. Although staff interviews confirmed that the resident experienced a decline, was assessed by nursing staff, and emergency services were called, none of these events or the resident's passing were recorded in the medical record. Another resident who expressed suicidal ideations did not have appropriate nursing documentation following the incident. While progress notes indicated the resident made statements about self-harm and staff redirected her, there was no evidence of follow-up or nursing assessment documented in the medical record, despite facility policy requiring such documentation for suicide threats. Interviews with facility leadership confirmed that nursing documentation was expected in these circumstances. Additionally, the facility failed to document a resident-to-resident altercation in both involved residents' medical records. While one resident's progress notes described the altercation and staff intervention, the other resident's record contained no documentation of the incident, contrary to facility policy requiring incident documentation for all involved parties. These omissions resulted in incomplete medical records that did not accurately reflect the care provided or the residents' conditions.
Failure to Ensure Safe Transfer and Documentation After Hoyer Lift Fall
Penalty
Summary
A resident with a history of acute respiratory failure and impaired physical mobility, who was assessed as cognitively intact, was involved in a transfer incident using a Hoyer lift. The care plan specified that two staff members and a Hoyer lift were required for transfers. During a transfer performed by a CNA and the Director of Nursing, the sling being used—brought with the resident upon readmission from the hospital—ripped, causing the resident to fall to the floor and strike her head. The resident was subsequently sent to the hospital, where no intracranial injuries or fractures were found. The incident was not documented in the electronic medical record, and there was uncertainty among staff regarding whether an incident report or progress note was completed. The facility's policy required the use of appropriate techniques and equipment to ensure resident safety, but the use of a potentially unsuitable sling and lack of documentation following the incident indicated a failure to follow established procedures. The administrator at the time of the survey was unable to locate any records or documentation related to the event.
Failure to Notify Hospice and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify hospice and the resident's representative in a timely manner regarding a change in condition for one of the sampled residents, identified as R4. R4 experienced a change in her eating habits, which was not communicated to hospice or her representative. The facility's policy requires direct care staff to recognize and communicate significant changes in a resident's condition, such as a decrease in food intake, to the nurse. However, this protocol was not followed, leading to a delay in notifying the appropriate parties. R4 was admitted to the facility with diagnoses including senile degeneration of the brain, aphasia, and dysphagia, and was utilizing hospice services. Her care plan included monitoring food and fluid intake and notifying hospice of any changes in her condition. Despite this, R4's electronic medical record showed no meal intakes documented except for minimal amounts on specific dates. Staff reported that R4 had been unable to eat or drink for two to three days, but this information was not promptly communicated to hospice or her family member, who was her emergency contact. Interviews with facility staff revealed that there was a lack of communication regarding R4's condition. A Certified Occupational Therapy Assistant and a Certified Nurse Aide both noted R4's unusual refusal to eat, which was a significant change from her normal behavior. The Director of Nursing stated that hospice and family should be notified within a day if a resident is not eating or drinking, but questioned the accuracy of the information passed along by staff. Ultimately, hospice was only contacted after several days, and R4 was sent to the emergency room following the delayed notification.
Delayed Reporting of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident-to-resident abuse allegation within the required two-hour timeframe, as per their policy. The incident involved two residents, one with metabolic encephalopathy and the other with dementia and anxiety. The abuse was reported by a family member via email to the facility's former Admissions Director, who then informed the administration the following day. The incident was initially believed to involve a staff member, but upon investigation, it was found to be between two residents. The facility's policy requires immediate reporting of abuse allegations, defined as within two hours, but the report to the State Agency was delayed. The incident occurred when one resident allegedly backhanded another in the face and rammed her wheelchair into the other's wheelchair. The resident who reported the incident had moderately impaired cognition, while the alleged perpetrator had severely impaired cognition. Staff members, including CNAs, were informed of the incident on the night it occurred and reported it to the nurse on duty. However, the administration was not aware of the incident until the email was read the next day, leading to a delay in reporting to the State Agency. The Assistant Administrator was not involved in the initial reporting process and was unaware of the staff's immediate reporting to the nurse.
Inadequate Investigation of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged resident-to-resident abuse incident involving two residents. The facility's policy requires that all allegations be thoroughly investigated, including interviewing all staff members who had contact with the residents during the period of the alleged incident. However, the investigation did not include interviews with staff who were on duty during the shift when the incident occurred. The Assistant Administrator confirmed that the investigation was not thorough and acknowledged that not all relevant staff were interviewed. The incident involved two residents, one with moderately impaired cognition and the other with severely impaired cognition. The alleged incident occurred when one resident reportedly backhanded the other in the face and rammed her wheelchair into the other's wheelchair. The resident who reported the incident informed the nurse on duty, who addressed the situation. However, the investigation did not verify if all potential witnesses, including a specific agency staff member, were contacted. Interviews conducted during the investigation revealed inconsistencies and gaps in the information gathered. Some staff members reported hearing about the incident secondhand, while others did not witness the event but were aware of the residents' behaviors. The Assistant Administrator admitted to limited involvement in the investigation and could not confirm if all necessary interviews were conducted. The facility's failure to interview all relevant staff and thoroughly document the investigation led to the deficiency.
Medication Administration Deficiency for a Resident
Penalty
Summary
The facility failed to administer medications as scheduled for a resident, identified as R3, who was reviewed for medication administration. R3's medications were documented as not being administered or being administered late on multiple occasions. The facility's policy requires medications to be administered within one hour of their prescribed time, but this was not adhered to. R3, who had diagnoses including pulmonary hypertension, hypertension, and localized edema, experienced late administration of several medications, including hydralazine, fexofenadine, liothyronine, losartan, torsemide, and folic acid, over the course of several days. R3 reported receiving medications late or not at all, recalling specific issues on certain dates where medications scheduled for 8:00 AM were administered as late as 12:30 PM. The resident also reported experiencing chest pain and needing to request nitroglycerin when blood pressure medications were not given on time. The Director of Nursing confirmed the late medication administrations and stated the expectation that medications should be administered within an hour of the scheduled time.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 64.28% error rate observed during a medication administration task. Surveyors noted 18 errors out of 28 medication opportunities, affecting three residents. The errors primarily involved administering medications more than an hour past their scheduled time, contrary to the facility's policy that medications should be administered within one hour of their prescribed time unless otherwise specified. Resident 10, who has multiple diagnoses including end-stage renal disease and hypertension, received her 8:00 AM medications at 9:09 AM. The delay was attributed to RN3, who was new to the facility and behind on her medication pass due to residents lining up and talking at the medication cart. Similarly, Resident 11, with diabetes and myopathy, received her 8:00 AM medications at 9:47 AM, after she had already finished breakfast. CNA1, who administered the medications, was observed giving insulin and a lidocaine patch without a breakfast tray present. Resident 12, diagnosed with heart failure and pulmonary hypertension, received her 8:00 AM medications at 10:10 AM, except for lorazepam and bupropion, which she refused. CNA1 reported starting late and being pulled to other tasks, contributing to the delay. Interviews with staff revealed issues such as lack of access to the facility's contingency supply, out-of-town pharmacy delays, and other tasks like falls and lab draws interfering with timely medication administration. The Director of Nursing confirmed the expectation for medications to be administered within the specified time frame, acknowledging the late administrations.
Failure to Monitor and Report Change in Condition Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care to prevent hospitalization, as per professional standards of practice. The resident, identified as R18, experienced a change in condition that was not fully assessed or monitored by the facility staff. Despite R18's history of congestive heart failure and other significant health issues, the facility did not complete necessary assessments or notify the physician of the resident's condition changes, including a significant weight gain and increased fatigue. R18 was readmitted to the facility with diagnoses including decompensated heart failure. The resident's weight increased by 12 pounds within a day, yet there was no documentation of the provider being updated or an assessment being completed regarding this weight gain. Additionally, the resident exhibited symptoms such as increased fatigue, elevated heart rate, increased respirations, and changes in oxygen needs, but these were not communicated to the physician in a timely manner. The facility's failure to act on these changes resulted in R18 being hospitalized with conditions including atrial flutter and acute decompensated heart failure. Interviews with facility staff, including the Nurse Practitioner and Director of Nursing, revealed that the facility's processes for monitoring and reporting changes in condition were not followed. The staff did not notify the provider of R18's weight gain or changes in vital signs, and the nurse responsible for R18's care did not attend the educational sessions provided by the facility on change in condition and physician notification. This lack of adherence to protocols and communication led to the resident's hospitalization, highlighting a deficiency in the facility's care practices.
Ice Machine Cleaning Deficiency
Penalty
Summary
The facility failed to ensure that the ice machine was cleaned and disinfected properly, which has the potential to affect all 56 residents. During an inspection, a surveyor observed a layer of black film on the inside lid of the ice machine. The facility's policy, last revised in January 2024, states that the ice machine should be cleaned and sanitized regularly, with maintenance responsible for deep cleaning it quarterly and as needed. However, there was confusion among staff about who was responsible for cleaning the ice machine, with the Dietary Manager unsure of the responsible party and the Maintenance Director unaware of any regular cleaning schedule or outside vendor involvement. The Maintenance Director admitted to cleaning the ice machine randomly when time allowed, indicating a lack of a set cleaning schedule. The Nursing Home Administrator mentioned plans to acquire new ice machines and expressed an expectation for the machines to be clean. Despite these expectations, the facility's failure to maintain a regular cleaning schedule for the ice machine resulted in the accumulation of a black film, which could pose health risks if ingested by residents.
Improper Garbage Disposal and Unsanitary Conditions
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed by a surveyor on multiple occasions. During an initial tour of the kitchen, the surveyor, along with the Dietary Manager (DM), observed various types of waste, including used gloves, wet cardboard boxes, food waste, stagnant water, cigarette butts, and packing peanuts, scattered on the ground near the main garbage dumpster. The DM was unsure of who was responsible for ensuring proper disposal and cleanup of garbage that fell on the ground. Interviews with the Maintenance Director and other maintenance staff revealed a lack of clarity and enforcement regarding responsibilities for maintaining cleanliness around the dumpster area. The Maintenance Director and staff expressed expectations that any staff member who noticed garbage outside the dumpster should pick it up, but there was no consistent follow-through. The Nursing Home Administrator also indicated an expectation for garbage to be picked up around the dumpster, but the area was not consistently maintained in a sanitary condition, potentially leading to pest issues.
Deficiency in Infection Prevention and Control Program
Penalty
Summary
The facility has failed to establish a comprehensive infection prevention and control program, which is crucial for maintaining a safe and sanitary environment and preventing the transmission of communicable diseases. The deficiency was identified during an interview and record review, where it was noted that the facility does not maintain a staff infection control line list for illnesses or infections other than COVID-19. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that the facility only tracks COVID-19 cases among staff and does not have a comprehensive line list that includes other infections. The existing call-in log lacks critical information such as the last date worked, date symptoms started/resolved, return to work date, and type of infection, which are essential for ensuring that staff are appropriately excluded from work to prevent the spread of infections. Additionally, the facility's infection prevention and control policies have not been updated annually as required. Specific policies, such as the Legionella Water Management Program and the COVID-19 vaccination policies for residents and staff, have not been revised since 2022 and 2023, respectively. During the survey, the ADON/IP acknowledged that the policies should be reviewed annually and attempted to find more recent updates but was unable to do so. This lack of updated policies further indicates a deficiency in the facility's infection control program, potentially affecting all 56 residents in the facility.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had access to call lights or a means to call staff for assistance, as observed in the cases of four residents. Resident 23, who is cognitively intact, was observed sitting in a Broda chair with the call light out of reach, attached to the bed behind them. Resident 25, also cognitively intact, reported instances where the call light was not within reach, necessitating calls to the main number or yelling for staff attention. Resident 17, who is moderately cognitively impaired, similarly reported difficulties in reaching the call light and having to yell for assistance due to immobility. Resident 19, who is cognitively intact, was observed in a wheelchair with a call light tied to the bed rail and out of reach. During the survey, a tourniquet was left on Resident 19's arm after a blood draw, and the call light was not accessible for the resident to request assistance. The Nursing Home Administrator acknowledged the expectation that call lights should be within reach when residents are in their rooms or bathrooms. The facility's failure to provide accessible call lights for these residents constitutes a deficiency in meeting their needs and preferences for assistance.
Inadequate Water Temperature Management
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not ensuring appropriate water temperatures for residents. This deficiency was observed in multiple instances, affecting several residents. Resident R38, who is cognitively intact and relies on his bathroom sink for washing due to his inability to use the shower, reported consistently cold water in his bathroom. The surveyor confirmed this by measuring the water temperature at 85.2°F, which is below the comfortable range. Other residents, including R13, R17, and R27, also reported issues with cold water during showers. R17, who is moderately cognitively impaired, experienced discomfort due to cold showers and reported this to a CNA. Similarly, R13 and R27, both of whom require assistance for showering, expressed dissatisfaction with the water temperature, noting that it often remains cold despite staff efforts to let it run for a while. Interviews with staff, including CNAs and maintenance personnel, revealed that the water temperature issue is ongoing and has been reported by residents. However, there seems to be a lack of consistent communication and resolution, as some staff were unaware of the problem or had not reported it to maintenance. The Maintenance Director was not informed of issues in certain areas, indicating a breakdown in reporting and addressing the water temperature concerns effectively.
Failure to Notify Physicians of Critical Changes
Penalty
Summary
The facility failed to immediately consult with the resident's physician when there was a need to alter treatment for two residents. For one resident, identified as R49, the facility did not notify the provider of a positive urine culture and sensitivity result, which delayed the treatment decision. The urine culture report, indicating the presence of Klebsiella pneumoniae and Pseudomonas aeruginosa, was received on a holiday, and the nurse practitioner was not informed until several days later. The Director of Nursing acknowledged that the resident had not been treated for the positive culture and that the provider should have been contacted sooner. In another case, a resident identified as R18 missed nighttime medications, and the primary physician was not notified of this occurrence. The resident, who was cognitively intact, had diagnoses including heart failure, vascular disease, diabetes, and respiratory failure. The Registered Nurse who discovered the missed medications did not remember notifying the Director of Nursing and confirmed that the primary physician was not informed. The facility's policy on lab and diagnostic test results requires prompt physician notification in situations where lab results are abnormal or when a resident's clinical status is unstable. The policy also specifies that direct voice communication with the physician is preferred for immediate notifications. In both cases, the facility did not adhere to its policy, resulting in a delay in treatment for R49 and a lack of physician notification for R18's missed medications.
Failure to Implement Comprehensive Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was taking Eliquis, an anticoagulant medication. The care plan did not address the need for monitoring side effects such as bruising or bleeding, which are known risks associated with the medication. Despite the facility's policy requiring care plans to include measurable objectives and reflect recognized standards of practice, the resident's care plan lacked any mention of the anticoagulant therapy or the necessary monitoring for its side effects. The resident in question had a history of multiple falls and severe cognitive impairment, requiring staff assistance for daily activities. The resident's physician had prescribed Eliquis for atrial fibrillation, but the care plan did not reflect this treatment or the associated monitoring needs. Interviews with facility staff, including a registered nurse and the director of nursing, revealed that while staff were aware of the need to monitor for side effects, this was not documented in the resident's care plan or medication administration records.
Failure to Implement Repositioning Plan Leads to Pressure Injury
Penalty
Summary
The facility failed to ensure proper care to prevent the development of pressure injuries for a resident identified as being at risk. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the colon, type 2 diabetes, and hemiplegia, was assessed to be at risk for pressure injuries. Despite this assessment, the facility did not implement a repositioning plan as required by their policy. The resident's care plan mentioned a repositioning schedule for comfort and offloading, but no specific documentation of such a schedule was found in the resident's medical record. The resident, who is dependent on staff for repositioning, developed a new wound on the left calf, which was observed by an occupational therapist. The wound was described as a circular dark purple area with a scabbed center, indicating a pressure injury. Interviews with the resident revealed that staff did not regularly reposition him unless he used the call light to request assistance. The resident also mentioned that a pillow was placed under his legs in the recliner only after the wound developed, suggesting inadequate preventive measures were in place prior to the injury. Further interviews with facility staff, including a CNA and the DON, confirmed that the resident did not have a regular repositioning schedule. The DON stated that the root cause of the wound was determined to be the urinary catheter tubing sitting under the resident's leg while in the recliner. Despite the DON's assertion that the resident needed repositioning every 2-3 hours, there was no evidence of a consistent repositioning schedule being followed, contributing to the development of the pressure injury.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R49, maintained acceptable nutritional status and weight, which was a deficiency identified by surveyors. R49, who was at risk for malnutrition and had experienced weight loss, was not adequately monitored for meal intake. The facility's policy required monitoring of resident weights and meal intakes, but R49's meal intake was not consistently documented, and significant weight loss was not addressed in a timely manner. R49 was admitted with multiple diagnoses, including colon cancer, diabetes, and malnutrition, and was on a low fiber diet with specific dietary instructions. Despite these conditions, R49 experienced a weight loss of 26 pounds, or 10.68%, over three months, which was not reviewed until June 18, 2024. The facility's records showed inconsistent documentation of R49's meal intake, with only 20 meals charted out of a possible 246 over 82 days, indicating a lack of proper monitoring and documentation. Interviews with facility staff, including the Dietary Manager and Director of Nursing, revealed communication gaps and unclear responsibilities regarding dietary orders and documentation of meal intake. The Registered Dietician noted limited documentation of R49's meal and supplement consumption, and the Dietary Manager confirmed that R49 often refused the main meal and had specific meal preferences. The Director of Nursing acknowledged that CNAs were responsible for documenting resident intake, but this was not consistently done, contributing to the oversight of R49's nutritional needs.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that all residents received their scheduled medications on time as per physician orders, specifically affecting one resident. The resident, who was cognitively intact and had a history of heart failure, vascular disease, diabetes, and respiratory failure, did not receive their nighttime medications on a specified date. The medications included Lantus Solostar Insulin, Dicloxacillin, Eliquis, Fluticasone Propionate, Lipitor, Metoprolol Succinate, Potassium Chloride, Singulair, and Symbicort. The medications were not administered as the documentation did not support that vital signs were completed by the PM shift, and this was noted in the Medication Administration Record (MAR) the following day. The issue was discovered by an RN who documented the lack of administration on the MAR but did not verify with the previous shift if the medications were given. The Director of Nursing (DON) was unaware of the missed medications and indicated that if medications are not signed out, it means they were not given, classifying this as a medication error. The Nursing Home Administrator acknowledged the concern, emphasizing the importance of signing out medications on the MAR to confirm administration. The failure to administer medications as scheduled was identified as a deficiency by the surveyors.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to ensure that drug regimens were free of unnecessary psychotropic medications and that a resident taking such medication had a care plan that included targeted behaviors. Specifically, Resident R11 was prescribed Bupropion, Quetiapine, and Sertraline for mood disorders, but the care plan did not include behavior monitoring to assess the effectiveness of these medications. The facility's policy on psychotropic medication use requires that residents not receive medications that are not clinically indicated and that there be adequate monitoring for efficacy and adverse consequences. However, the care plan for R11 lacked specific behaviors to monitor, which is crucial for determining the effectiveness of the prescribed medications. Interviews with facility staff revealed a lack of clarity and training regarding behavior monitoring for residents on psychotropic medications. Certified Nursing Assistants (CNAs) reported relying on report sheets and care cards for information on behaviors to monitor, but these documents did not contain specific behaviors for R11. Additionally, the CNAs had not received training on individualized behavior monitoring. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged that the targeted behaviors listed in the Treatment Administration Record (TAR) were not specific to R11 and that the care plan should have been updated to reflect individualized behaviors. The deficiency was further highlighted by the fact that the facility's electronic medical record system did not pull individualized behaviors into the care plan, as confirmed by the DON. This oversight resulted in a generalized approach to behavior monitoring, which did not account for the specific needs of R11. The lack of individualized behavior monitoring and documentation meant that the facility could not adequately assess the effectiveness of the psychotropic medications prescribed to R11, thereby failing to comply with their own policy and regulatory requirements.
Medication Administration Errors Result in 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during a medication pass task. This deficiency involved Registered Nurse (RN) D, who did not administer medications to Resident R46 according to the physician's orders. Specifically, RN D incorrectly administered Hydrocortisone by breaking a 10 mg tablet in half instead of using the prescribed 5 mg tablet for the 2 PM dose. Additionally, RN D administered Carvedilol without providing a snack or meal, as required by the medication's instructions, and did so outside the acceptable time frame of one hour before or after the scheduled time. Resident R46, who has a diagnosis of Peripheral Vascular Disease and Hypertension, was affected by these medication errors. The physician's orders specified that Hydrocortisone should be administered as 10 mg at 8 AM and 5 mg at 2 PM, while Carvedilol should be given twice daily with meals. The Assistant Director of Nursing (ADON) C confirmed these errors, noting that the pharmacy should have provided the correct tablet strength and that RN D should not have split the tablet. ADON C acknowledged these actions as medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the cases of two residents, R7 and R18. R7, who has multiple medical conditions including Multiple Sclerosis and Autonomic Dysreflexia, was prescribed Midodrine to be administered three times a day with the instruction to hold the medication if the systolic blood pressure exceeded 130. Despite this, the medication was administered on multiple occasions when R7's systolic blood pressure was above the specified limit, resulting in six significant medication errors. The errors were observed and confirmed by both the resident and the nursing staff, indicating a failure in adhering to the prescribed parameters for medication administration. R18, who has diagnoses including heart failure and diabetes, did not receive nighttime medications, including insulin, on a specific date. The MAR indicated that the medications were not signed out, and the RN who discovered the omission did not verify whether the medications were administered. The DON was unaware of the omission, and it was confirmed that the medications were not given, constituting a medication error. The failure to administer the prescribed insulin and other nighttime medications was acknowledged by the nursing home administrator and the DON. The facility's policy on administering medications requires that medications be given in a safe and timely manner, as prescribed, and within one hour of the scheduled time. However, the incidents involving R7 and R18 demonstrate a deviation from this policy, with medications being administered outside of the ordered parameters and not being administered at all. The staff involved acknowledged the errors, and the facility's leadership recognized the deficiencies in medication administration practices, which were identified during the surveyor's investigation.
Failure to Administer Follow-up Pneumococcal Vaccine
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures for ensuring that residents receive appropriate pneumococcal vaccinations. Specifically, the facility did not offer a resident, identified as R41, the necessary follow-up pneumococcal vaccine after they became eligible. R41 had received the Pneumococcal 23 vaccine on July 5, 2022, and according to CDC recommendations, should have been offered a dose of the Pneumococcal 15 or Pneumococcal 20 vaccine at least one year later. However, the facility did not offer this subsequent vaccination, and there was no documentation indicating that the resident received or declined the additional vaccine. The deficiency was identified during a surveyor's review of R41's immunization record and the Wisconsin Immunization Registry (WIR) report, which confirmed the absence of any further pneumococcal vaccinations after the initial dose. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) acknowledged the oversight and indicated that the current process for tracking vaccine eligibility involved checking the WIR every few months. This process failed to ensure timely vaccination for R41, who had chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation, conditions that necessitate vigilant immunization practices.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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