Kinnic Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in River Falls, Wisconsin.
- Location
- 1663 E Division St, River Falls, Wisconsin 54022
- CMS Provider Number
- 525513
- Inspections on file
- 22
- Latest survey
- June 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Kinnic Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain a full-time DON after the previous DON resigned, resulting in a gap where only part-time DON coverage was provided and the ADON, an LPN, was on vacation. This left the facility without a full-time DON for an extended period.
A resident with a VP shunt did not receive care in line with professional standards, as staff only performed the mechanical pumping of the shunt without documenting the number of pumps or conducting required assessments for infection or abdominal complications. Nursing staff reported limited training focused solely on pumping, and the DON could not provide evidence of education or assessment protocols for VP shunt care.
Three residents experienced falls, and the facility did not implement immediate interventions, conduct root cause analyses, or update care plans as required by its own policies. Incident reports and care plans lacked documentation of post-fall actions, and facility administration confirmed the absence of interdisciplinary team investigations.
Nursing staff did not receive formal training or competency evaluation for the care of a resident with a VP shunt, despite the resident's care plan requiring specific interventions. Staff training was limited to informal demonstrations, with no documented education on proper technique, assessment, or potential complications. The facility's training materials did not include VP shunt care, and the DON could not provide evidence of staff competency in this area.
Staff did not follow proper food storage and thermometer sanitization procedures, including storing mixing bowls and pans uncovered and not inverted, and failing to allow thermometer probes to air dry after sanitizing before checking food temperatures. These actions had the potential to affect all residents in the facility.
The facility submitted inaccurate direct care staffing data to CMS through the PBJ system, resulting in reports of excessively low weekend staffing for three consecutive quarters. Although actual schedules and staff interviews confirmed consistent staffing levels throughout the week, discrepancies in PBJ data entry—potentially due to unreported staff hours or incorrect timecard entries—led to the deficiency.
The facility failed to conduct and document annual performance reviews for CNAs, as required. A review of records for three CNAs showed no evidence of completed evaluations, and the administrator confirmed that only wage adjustment forms were available. This deficiency had the potential to impact all residents in the facility.
Two residents who were discharged from Medicare Part A services but remained in the facility were not given the required Advanced Beneficiary Notice (ABN) informing them of their financial liability for services not covered by Medicare. The Business Office Manager indicated she had misinterpreted the updated forms and failed to provide the necessary notice.
A resident with a suprapubic catheter did not receive proper site care due to the absence of a facility policy and failure by a registered nurse to perform hand hygiene and glove changes between removing a soiled dressing and applying a new one. The resident, who had a history of UTI with sepsis and complex medical needs, was put at risk due to these lapses in infection control.
A resident with PTSD and a history of childhood trauma was not assessed for trauma triggers, and the care plan lacked individualized, trauma-informed interventions. Staff were unaware of the resident's trauma history or specific care approaches, and the facility did not complete trauma-informed assessments as required by policy.
Surveyors observed that an LPN had not removed an expired bottle of refrigerated omeprazole from the medication storage room, and the medication continued to be administered to a resident after its expiration date. Facility policy requires staff to check expiration dates and remove expired medications, but this was not followed, resulting in expired medication being given to a resident.
A resident with a suprapubic catheter did not receive proper infection control during site care, as an RN failed to perform hand hygiene and change gloves after removing a soiled dressing and before applying a new one. The facility also lacked a specific policy for suprapubic catheter care, and the existing hand hygiene policy was undated and general.
A resident with complex medical needs was denied the right to choose a VA wound care provider, as the DON required use of only in-house providers and disregarded the resident's and family's wishes. When the resident returned from a VA appointment with new wound care orders, the DON instructed staff not to implement them, had the attending physician discontinue the orders, and removed the related supplies, violating the resident's rights.
A resident with severe cognitive impairment and dementia was subjected to verbal abuse by a nurse, while another staff member intimidated the resident and failed to intervene appropriately. The facility did not ensure all staff were trained on abuse prevention policies, as shown by incomplete training records, and did not conduct formal audits or have a written quality improvement plan to address or prevent further abuse.
A resident with severe cognitive impairment and multiple medical conditions was subjected to alleged verbal abuse by a nurse, which was not reported by a CNA within the required two-hour timeframe. The incident was instead reported the following morning, and local law enforcement was not notified as required. The facility's investigation and reporting to the state agency were also delayed, resulting in a deficiency in abuse reporting procedures.
A resident with significant hearing and vision impairments did not receive a replacement for a broken hearing aid for several months, despite care plan directives and observed communication difficulties. Staff were required to speak loudly into the resident's functioning ear, and the lack of a systematic process for follow-up led to prolonged inadequate access to necessary assistive devices.
The facility failed to provide written transfer notices to three residents, omitting necessary details such as the reason for transfer, location, and appeal rights. Staff interviews and record reviews revealed that only verbal notifications were given, and the provided transfer forms were incomplete and lacked signatures from the residents' representatives.
A facility failed to create a behavioral care plan for a resident with a history of being on the sex offender list. Despite the resident's intact cognition and need for assistance with mobility, the care plan did not address potential inappropriate sexual behaviors. Interviews with the NHA and DON revealed awareness of the issue but no interventions were in place.
The facility failed to comply with food safety standards as staff, including the Dietary Manager and Dietary Cook, were observed not wearing beard nets while preparing and serving food, despite having facial hair. This non-compliance had the potential to affect all 46 residents.
The facility failed to provide necessary toileting and incontinence care for two residents with cognitive impairments. Staff did not follow care plans, resulting in prolonged periods without toileting assistance, leading to inadequate personal hygiene and potential health risks.
A resident with obstructive sleep apnea did not receive necessary respiratory care as the facility failed to replace CPAP supplies according to the manufacturer's recommendations. Interviews with staff revealed no system in place to track or document the replacement of the resident's CPAP supplies, and the Director of Nursing admitted that they do not review the resident's personal CPAP machine.
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers for two residents, as staff were unaware of this requirement. This deficiency was confirmed by the Director of Nursing and Social Services Director during a survey.
Lack of Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure full-time Director of Nursing (DON) coverage, as required. After the resignation of the previous DON, there was no full-time DON in place from 6/17 to 6/30. During this period, the newly hired DON worked only part-time and was not scheduled to begin full-time until August. The Assistant Director of Nursing (ADON), who is a Licensed Practical Nurse (LPN), was present full-time but was on vacation during the survey. Interviews with staff confirmed that there was no interim full-time DON assigned during this gap, potentially affecting all 48 residents in the facility.
Failure to Monitor and Assess VP Shunt According to Standards
Penalty
Summary
The facility failed to ensure that a resident with a ventriculoperitoneal (VP) shunt received treatment and care in accordance with professional standards of practice. The resident, who had congenital hydrocephalus and a cerebrospinal fluid drainage device, was severely cognitively impaired and required regular monitoring of the VP shunt for complications such as infection or malfunction. The care plan directed nursing staff to pump the shunt as per neurosurgeon instructions but did not include interventions for assessment of the shunt line for infection or abdominal assessment for signs of fluid overload related to cerebrospinal fluid drainage. Review of the resident's records showed that while the shunt was pumped as ordered, there was no documentation of the number of pumps performed, nor were there any documented assessments of the abdomen or the shunt for signs of infection or other complications. Interviews with nursing staff revealed that their training was limited to the mechanical aspect of pumping the shunt, with no education or documentation regarding assessment for potential complications. The Director of Nursing was unable to provide evidence of staff training or assessment protocols related to the VP shunt, and no additional physician orders for assessment were present.
Failure to Implement Post-Fall Interventions and Care Plan Revisions
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and interventions to prevent accidents for three residents. Despite having policies in place for falls management and post-fall protocols, the facility did not implement immediate interventions after falls, did not conduct root cause analyses, and did not update or revise care plans following fall incidents. This was observed through record reviews, interviews, and incident reports for three residents who experienced falls. One resident with severe cognitive impairment and a history of multiple falls was found on the floor with a head injury, but the incident report lacked documentation of immediate interventions or care plan updates. Another resident with hemiplegia and a history of falls prior to admission experienced a fall while attempting to put shoes away, yet the incident report did not include immediate interventions, and there was no evidence of an interdisciplinary team investigation or care plan revision. A third resident with severe cognitive impairment and a cerebrospinal fluid drainage device fell from a wheelchair, sustained a hematoma and abrasions, and was sent to the emergency department, but there was no documentation of a root cause analysis or follow-up occupational therapy evaluation as indicated in the care plan. In all three cases, the facility did not follow its own policies regarding post-fall assessment, investigation, and care plan revision. The lack of immediate interventions, root cause investigations, and care plan updates after falls contributed to the deficiency, as confirmed by the absence of interdisciplinary team notes and the statements from facility administration.
Lack of Staff Competency and Training for VP Shunt Care
Penalty
Summary
Licensed nurses at the facility did not have the specific competencies and skill set necessary to care for a resident with a ventriculoperitoneal (VP) shunt, as identified through the resident's assessment and care plan. The facility's own assessment and training documentation indicated that staff competencies should be based on the clinical characteristics of the resident population, with a curriculum and training plan developed accordingly. However, review of facility education and training materials showed that VP shunt care was not included as a topic for training or competency evaluation. The resident in question had a history of congenital hydrocephalus and a cerebrospinal fluid drainage device, with severe cognitive impairment noted on the most recent assessment. The care plan required nursing staff to pump the VP shunt as directed by the neurosurgeon, but did not include assessment for signs or symptoms of infection or fluid overload related to the shunt. Interviews with nursing staff revealed that training on VP shunt care was informal and limited to being shown how to palpate and pump the shunt, with no formal education on the amount of pressure, rate, or depth of compression, nor on potential complications or necessary assessments beyond monitoring neurological status. Staff were unable to articulate additional assessments or complications related to VP shunt malfunction. The Director of Nursing was unable to provide documentation of training or competency evaluation for VP shunt care and confirmed that no current training was in place for this procedure.
Improper Food Storage and Thermometer Sanitization Practices
Penalty
Summary
Staff failed to follow professional standards for food service safety in the preparation, distribution, and serving of food. During a kitchen tour, a surveyor observed that mixing bowls and pans were stored uncovered and not inverted, both on counters and racks. The kitchen aide confirmed that this was the usual practice, and acknowledged understanding of the risk of bacterial contamination associated with storing dishes in this manner. The dietary manager also confirmed that dishes should be covered or inverted, and noted that moisture remaining after dishwashing could promote bacterial growth, especially since the storage areas were not protected from potential contaminants. Additionally, a staff member responsible for checking food temperatures was observed using an alcohol pad to wipe the thermometer probe, but did not allow the probe to air dry before inserting it into multiple food items. The staff member admitted to not being trained to wait for the sanitizer to dry before use and recognized the potential for contaminating food with sanitizer residue. These practices had the potential to affect all 49 residents in the facility.
Inaccurate PBJ Staffing Data Submission Resulted in Reported Low Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) via the Payroll Based Journal (PBJ) system for the period from July 1, 2024, to March 31, 2025. Despite scheduling the same number of direct care staff on weekends as on weekdays, the PBJ data submitted indicated excessively low weekend staffing for three consecutive fiscal quarters. This discrepancy was identified through review of CASPER 1705D reports and was not supported by the facility's actual staffing schedules or by interviews with the scheduler and the nursing home administrator (NHA), both of whom confirmed that weekend staffing levels did not differ from weekday levels except for the absence of the DON or ADON. The NHA reported that staff hours worked are submitted to the owner through the payroll system and then entered into the PBJ system by the owner. Attempts to verify the data entry process with the owner were unsuccessful. The NHA suspected that some staff hours may have gone unreported in the PBJ system due to incorrect timecard entries, which may have triggered the low weekend staffing reports. The surveyor did not find evidence of actual low weekend staffing during the review, but the inaccurate PBJ data submission constituted a deficiency affecting all 49 residents in the facility.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility did not ensure that Certified Nursing Assistants (CNAs) received annual performance reviews as required. During a review of personnel records for three CNAs, it was found that none had documentation of a performance review within the past 12 months, despite being employed at the facility for more than a year. The Nursing Home Administrator confirmed that only wage adjustment forms were available, and no annual performance evaluations could be located for any of the CNAs reviewed. This lack of a system for conducting and documenting regular performance reviews was observed to potentially affect all 49 residents in the facility.
Failure to Provide ABN and Notice of Liability After Medicare Part A Discharge
Penalty
Summary
The facility failed to provide Advanced Beneficiary Notice (ABN) of non-coverage to residents whose Medicare Part A coverage was discontinued while they still had benefit days remaining. Specifically, two residents were discharged from Medicare Part A services but remained in the facility without being given notice of their financial liability for services not covered by Medicare after their coverage ended. Documentation review showed that both residents received a notice of non-coverage, but no ABN or notice of patient liability was provided. During an interview, the Business Office Manager responsible for these notices stated that she had misinterpreted the updated forms and had not been providing the required notice of potential liability to residents who remained in the facility after Medicare coverage ended.
Deficient Suprapubic Catheter Site Care and Infection Control
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not receive appropriate catheter site care due to the facility's lack of a specific policy guiding daily suprapubic catheter site care. During an observation, a registered nurse performed suprapubic catheter care but failed to change gloves or perform hand hygiene after removing the old dressing and before applying a new dressing. This lapse in infection control practice was directly observed and acknowledged by both the nurse and the assistant director of nursing when questioned. The facility's existing policy on suprapubic catheterization did not address hand hygiene between glove changes during site care, and a new policy created during the survey still omitted this critical step. The resident involved had multiple sclerosis, neuromuscular dysfunction of the bladder, and an appendicovesicostomy, and was cognitively intact. The resident had previously experienced a urinary tract infection with sepsis. The lack of a clear policy and failure to follow proper infection control procedures during catheter care were directly linked to the deficiency cited by surveyors.
Failure to Assess and Care Plan Trauma-Informed Approaches for Resident with PTSD
Penalty
Summary
The facility failed to assess and care plan person-centered, trauma-informed approaches for a resident with a known history of trauma and a diagnosis of post-traumatic stress disorder (PTSD). The facility's policy requires a multi-pronged approach to identifying trauma history and triggers, including the use of assessment tools and direct inquiry with the resident. However, the resident's record did not contain any trauma-specific assessment, and the care plan lacked individualized interventions to prevent re-traumatization. The resident in question was admitted with multiple mental health diagnoses, including major depressive disorder, Alzheimer's disease, unspecified psychosis, panic disorder, and PTSD related to the death of her sister during childhood. Although the care plan acknowledged the PTSD diagnosis and referenced the traumatic event, it only included general interventions such as medication administration, encouragement to express feelings, and monitoring for symptoms of depression or anxiety. There were no documented efforts to identify specific trauma triggers or to develop targeted strategies to minimize re-traumatization, as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's trauma history and the absence of trauma-informed care approaches. The Social Service Director confirmed that trauma-informed assessments were not being completed for residents with identified trauma, and direct care staff were unaware of the resident's PTSD diagnosis or any specific interventions related to her trauma. Staff noted the resident's sensitivity to environmental stimuli and recent distress related to news events, but had not been provided with guidance on how to address these issues in a trauma-informed manner.
Expired Medication Not Removed from Active Stock
Penalty
Summary
Surveyors found that the facility failed to ensure expired medications were removed from active stock in the medication storage room refrigerator. During an observation with an LPN, a bottle of refrigerated liquid omeprazole intended for a resident was found to be labeled with a beyond use date that had already passed. The medication had continued to be administered to the resident after its expiration date, and no other expiration dates were noted on the bottle at the time of observation. The facility's policy requires staff to observe proper storage and labeling requirements for all medications, including the removal of expired medications from active stock. The Assistant Director of Nursing confirmed that nursing staff are expected to check expiration dates before administering medications and that all refrigerated medications are inspected weekly. Despite these expectations, the expired medication remained in use and was not removed in a timely manner, affecting one resident.
Failure to Perform Hand Hygiene and Glove Change During Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to perform appropriate hand hygiene and glove changes during suprapubic catheter site care for a resident. The RN performed hand hygiene and donned personal protective equipment upon entering the room, but after removing the old dressing from the catheter site, did not change gloves or perform hand hygiene before cleaning the site and applying a new dressing. The RN only performed hand hygiene after completing the procedure and removing personal protective equipment. This practice was observed directly by the surveyor. Additionally, the facility did not have a specific policy in place to guide staff on the care of suprapubic catheter sites. The existing hand hygiene policy was undated and only provided general guidance on when hand hygiene should be performed, such as after handling contaminated objects or before invasive procedures. Interviews with facility staff confirmed that hand hygiene and glove changes should occur after removing a soiled dressing and before applying a new one, but this was not followed during the observed care. The resident involved was cognitively intact and had a history of multiple sclerosis, neuromuscular bladder dysfunction, and an appendicovesicostomy.
Failure to Honor Resident's Right to Choose Physician and Treatment
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician and treatment options. A resident with multiple medical conditions, including a left femur fracture, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and venous ulcers, expressed a preference to continue wound care with a VA provider rather than the facility's in-house provider. Despite this, the resident was told upon admission to cancel all VA appointments except for orthopedic care and to use only in-house providers. When the resident and their daughter arranged for VA wound care and returned with new treatment orders, the Director of Nursing (DON) instructed staff not to follow the VA provider's orders and had the attending physician discontinue them without the resident's consent. The supplies for the VA-ordered treatments were removed from use and stored away, and the new orders were not transcribed or implemented. Interviews with staff confirmed that the DON directed all care decisions through the medical director and disregarded the resident's expressed wishes and the VA provider's orders. The Social Services Director acknowledged that residents have the right to choose their own physicians, as stated in the admission packet, and agreed that changing provider orders without resident consent was a violation of rights. The Director of Rehab also reported that the DON refused to allow staff to implement the VA provider's orders and removed the related supplies. The Nursing Home Administrator confirmed awareness of the DON's actions and stated that residents have the right to select their providers.
Failure to Protect Resident from Verbal Abuse and Inadequate Staff Training
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. A resident with severe cognitive impairment, dementia, and other significant medical conditions was subjected to verbal abuse when a registered nurse raised his voice and swore at the resident while providing care. Additionally, a certified nursing assistant was reported to have intimidated the resident and did not attempt appropriate interventions. The incident was reported by another staff member, and the facility's investigation confirmed the occurrence of verbal abuse. The facility did not ensure that all staff were trained on the abuse policy, as evidenced by incomplete staff sign-in sheets for abuse education and reporting. Out of 78 staff employed at the time, only a portion received documented training following the incident, and some staff, including the involved nurse, were not listed as having received prior abuse training. Furthermore, the facility did not conduct formal audits of staff interactions or knowledge of the abuse policy to prevent further incidents. There was also no written quality improvement or performance improvement plan in place to address or track patterns of abuse occurrences.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of an allegation of verbal abuse in accordance with section 1150B of the Act. Specifically, a certified nursing assistant (CNA) witnessed a registered nurse (RN) raising his voice and swearing at a resident with severe cognitive impairment during care. The CNA did not report the incident immediately or within the required two-hour timeframe, instead waiting until the following morning to inform the Assistant Director of Nursing (ADON). The ADON then reported the incident to the Director of Nursing (DON), who subsequently notified the Nursing Home Administrator (NHA). The incident was not reported to local law enforcement as required by state law, and the facility's investigation was not completed and reported to the state agency until several days later. The resident involved had significant medical conditions, including a nondisplaced femur fracture, dementia with severe cognitive impairment, and required moderate assistance with daily activities. The Minimum Data Set (MDS) assessment documented the resident's severe cognitive impairment and need for extensive support. The failure to report the alleged verbal abuse in a timely manner, as outlined in facility policy and federal requirements, constituted a deficiency in the facility's abuse reporting procedures.
Failure to Replace Resident's Hearing Aid in Timely Manner
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, low vision, blindness in one eye, and mild cognitive impairment did not receive proper treatment and assistive devices to maintain hearing abilities. The resident's care plan indicated the need for bilateral hearing aids and assistance with their use, as well as regular monitoring and referral to audiology as needed. Despite these documented needs, the resident's left hearing aid was broken and not replaced for several months, resulting in ongoing difficulty hearing from the left side. Staff were observed speaking loudly into the resident's right ear, and the resident was unable to respond when addressed from the left side, indicating a significant impact on communication. Interviews revealed that the process for replacing the hearing aid was not effectively managed. The Social Service Director acknowledged that follow-up was delayed, partly due to a change in the resident's Power of Attorney after the death of a family member who had possession of the hearing aid. The lack of a systematic approach to tracking and replacing assistive devices contributed to the prolonged period without the necessary hearing aid, directly affecting the resident's ability to communicate and participate in daily activities.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of transfer to three residents, which included necessary information such as the reason for transfer, the location, and appeal rights. This deficiency was identified during a review of the facility's policy and records, as well as through interviews with staff. The policy required that the transfer/discharge notice be provided in a language and manner understandable to the resident and their representative, including specific details about the transfer and appeal rights. For Resident 2, the electronic medical record showed no evidence of a written notice of transfer being provided. The registered nurse on duty at the time of the transfer confirmed that no written notice was given, only a verbal notification to the resident's responsible party. The administrator later provided a transfer form that lacked the necessary contact information for filing an appeal and did not have a signature from the resident's wife. Similarly, for Residents 7 and 8, there was no evidence of written notice of transfer with the required information being provided. The administrator provided transfer forms that were incomplete and lacked signatures from the residents' representatives. Interviews with the administrator and the director of nursing revealed that while a bed hold notice was given, it did not include the required details about the transfer or appeal rights.
Lack of Behavioral Care Plan for Resident with History of Sexual Offense
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident identified as R4, who was admitted with a history of being registered on the sex offender list for minor issues. Despite R4 having intact cognition and requiring assistance for mobility and transfers, the facility did not create a behavioral care plan to address potential inappropriate sexual behaviors. The Minimum Data Set (MDS) assessment confirmed R4's cognitive status, and the admission documentation noted R4's history of illicit sexual behavior. However, the care plan lacked targeted interventions to manage these potential behaviors. During interviews, both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged the absence of a behavioral care plan for R4. The NHA admitted that the facility was trying to keep the situation low key to avoid turmoil for R4, while the DON confirmed that no complaints had been made about R4's behavior and described R4 as pleasant. Despite this, both agreed that interventions should be in place to address any potential inappropriate sexual behaviors, but no such care plan existed at the time of the survey.
Non-Compliance with Food Safety Standards Due to Lack of Facial Hair Coverings
Penalty
Summary
The facility did not adhere to professional standards for food service safety, as staff were observed not wearing appropriate facial hair coverings while preparing and serving food in the kitchen. Specifically, the Dietary Manager (DM) and Dietary Cook (DC) were seen without beard nets, despite having facial hair. The FDA Food Code 2022 mandates that food employees wear hair restraints, including beard nets, to prevent hair from contacting exposed food and clean equipment. The facility's policy also requires staff to wear hair restraints when handling food. However, both DM and DC were observed multiple times without beard nets while working in food prep areas and serving food to residents. During interviews, the DM and DC were unsure about the specific policy regarding facial hair but acknowledged the need to wear beard nets. The DM admitted to instructing staff to either shave or wear beard nets but did not follow this guideline himself, believing it was unnecessary since he was not directly handling food. This non-compliance with food safety standards had the potential to affect all 46 residents in the facility.
Failure to Provide Necessary Toileting and Incontinence Care
Penalty
Summary
The facility did not ensure that two residents who were unable to carry out activities of daily living received the necessary services of toileting and incontinence care to maintain good personal hygiene. Resident R16, who has severe cognitive impairment and is frequently incontinent, was observed multiple times throughout the day without being offered toileting assistance. Despite R16's care plan specifying that staff should reattempt toileting every 5-10 minutes if the resident resists, staff did not follow this protocol. R16 was left in a soaked brief for an extended period, leading to redness on the resident's bottom, indicating potential skin breakdown and discomfort. Similarly, Resident R29, who has moderate cognitive impairment and is incontinent of urine, was not offered toileting assistance at appropriate intervals. Observations showed that R29 was taken to various locations within the facility without being asked if toileting was needed. It was only after a significant period that staff noticed a strong urine smell and found R29's brief soaked with urine. The resident had not been toileted or checked since the morning, contrary to the care plan that requires regular checks and toileting every two hours. Both residents' care plans were not adhered to, resulting in prolonged periods without necessary toileting and incontinence care. The staff's failure to follow the individualized care plans and reattempt toileting as specified led to inadequate personal hygiene and potential health risks for the residents. The observations and interviews with staff highlighted a lack of compliance with the care plans, contributing to the deficiencies noted in the report.
Failure to Replace CPAP Supplies According to Manufacturer's Recommendations
Penalty
Summary
The facility did not ensure that a resident received necessary respiratory care and services in accordance with professional standards of practice. The resident, who has diagnoses including obstructive sleep apnea, insomnia, muscle weakness, and hypertension, uses a CPAP machine. The facility's policy requires following the manufacturer's instructions for the frequency of cleaning and replacing CPAP equipment. However, the facility failed to document or replace the resident's CPAP supplies, such as the mask, hose, headgear, air filter, and water chamber, according to the manufacturer's recommendations. The resident and their significant other expressed concerns about the lack of replacement of CPAP supplies for an extended period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that there was no system in place to track or document the replacement of the resident's CPAP supplies. The LPN was unable to find any records indicating when the supplies were last replaced, and the DON admitted that they do not review or inspect the resident's personal CPAP machine. The facility relies on a respiratory therapist from an external provider to inspect supplies monthly, but there was no information available about the last replacement of the resident's CPAP supplies.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility did not provide written notification of transfer to the Office of State Long-Term Care Ombudsman for two residents reviewed for transfers. The facility lacked a system to ensure the Ombudsman was notified of hospital transfers, which had the potential to affect all 46 residents in the facility. This deficiency was identified during a survey when the Director of Nursing (DON) and Social Services Director (SSD) confirmed that staff were unaware of the requirement to notify the Ombudsman. One resident was hospitalized in September 2023, and the surveyor requested the Ombudsman notification on May 1, 2024. The DON confirmed that the facility had not been providing the required notifications. Another resident, who had multiple diagnoses including type 2 diabetes mellitus and chronic kidney disease, experienced a change in condition and was transferred to the emergency room. The surveyor found no documentation of Ombudsman notification for this transfer, which was confirmed by the DON.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
