Lafayette Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Darlington, Wisconsin.
- Location
- 719 E Catherine St Box 167, Darlington, Wisconsin 53530
- CMS Provider Number
- 525362
- Inspections on file
- 30
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Lafayette Manor during CMS and state inspections, most recent first.
Two CMAs were found to have access to keys for the locked narcotic box and medication storage room, contrary to facility policy and their job descriptions, which prohibit them from handling or administering narcotics. Both CMAs confirmed they held the keys and participated in narcotic count verifications, while nursing staff and administration confirmed that only nurses are authorized to access and dispense narcotic medications.
Staff failed to immediately report two resident-to-resident altercations, including verbal threats and aggressive behavior, to both the administrator and the State Survey Agency as required by policy. An LPN documented the incidents but only reported one to the administrator, and neither was reported to the State Agency. Both the LPN and administrator later acknowledged that these events should have been reported as allegations of abuse.
Staff failed to investigate documented resident-to-resident altercations involving two residents, despite facility policy requiring immediate investigation of suspected abuse. An LPN recorded incidents where a resident yelled, threw an object, and made threats toward others, but no follow-up investigation was performed.
A resident with a high risk for pressure ulcers did not receive necessary treatment and services, leading to a deficiency in care. The facility failed to implement and document interventions, such as pressure-relieving devices and consistent wound care, resulting in the resident's pressure injury worsening. The lack of communication and coordination among staff, along with an environmental emergency, further contributed to the deficiency.
A resident in hospice care, suffering from serious medical conditions, was subjected to abuse by a CNA who ignored the resident's requests to stop care, causing pain and distress. Despite the presence of other staff, no intervention occurred. The facility's policies on abuse prevention were not effectively implemented, and the incident was not reported to the state agency in a timely manner.
The facility did not adhere to professional standards for food service safety, affecting all residents. Observations included improperly dated food items, a staff member without a hairnet in the kitchen, and a scoop stored inside a sugar container, raising concerns about cross-contamination and infection control.
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) system, as required by their policy, to identify and address quality deficiencies. The Nursing Home Administrator admitted to conducting only one QAPI meeting since October and confirmed that no Performance Improvement Projects (PIPs) were in place, citing leadership changes as a barrier. This deficiency potentially affects all 39 residents.
The facility's QAA Committee did not include the required members, specifically the Infection Preventionist (IP), in any of the quarterly meetings over the past year. The Nursing Home Administrator was unaware of the IP's required attendance, despite the facility's policy stating otherwise. This deficiency could potentially impact all 39 residents in the facility.
The facility failed to establish an effective infection prevention and control program, with surveyors observing water dripping near residents during meals and a lack of tracking for MDROs. The facility's infection rates were not segregated by type, hindering trend identification. Additionally, the facility lacked a comprehensive water management program, missing key documentation on the building's water system and control measures.
The facility failed to properly label and store medications, as observed in two medication carts and storage rooms. An undated insulin pen, expired morphine tablets, and improperly dated cough syrup were found. Staff interviews revealed inconsistencies in understanding medication expiration protocols, with the DON and NHA acknowledging the responsibility of nurses and pharmacy audits in checking expiration dates.
Two residents experienced issues with weight monitoring and physician notification. One resident had weights recorded using different methods, leading to unclear accuracy, and the physician was not updated on weight changes. Another resident experienced a significant weight loss without physician notification, and there was no documentation of nutritional supplement trials. Interviews revealed inconsistencies in weighing methods and a lack of clear guidelines for notifying physicians about weight changes.
A resident with eczema did not receive a scheduled dose of Dupilumab due to a failure in the facility's pharmaceutical services. The medication was not administered on the scheduled date, and the oversight was not reported or addressed by the staff. The resident's condition worsened, and the issue was not resolved despite being raised by the resident's POAHC.
The facility failed to ensure appropriate use and monitoring of psychotropic medications for two residents. One resident was given Quetiapine without proper diagnosis or monitoring for agitation or aggression, while another resident's care plan lacked documentation on side effects to monitor for their medications. Staff interviews revealed a lack of knowledge about specific side effects, and the facility's policy on psychotropic medication use was not followed.
A resident under hospice care, diagnosed with malignant neoplasm and intracranial hemorrhage, reported pain during care by a CNA who continued despite the resident's request to stop. The facility failed to report the abuse allegation to the State Agency within the required two-hour timeframe, as the report was made several hours later. The Nursing Home Administrator confirmed the delay, acknowledging the breach of the facility's policy on immediate reporting.
A facility failed to thoroughly investigate an abuse allegation involving a resident under hospice care, who reported pain during care by a CNA. The investigation was incomplete, lacking necessary steps such as skin assessments for nonverbal residents and staff education on abuse. Interviews revealed other residents felt unsafe with the CNA, but the facility did not document all conversations or ensure adequate resident protection.
Three residents experienced multiple falls due to inadequate supervision and lack of individualized interventions. A resident with severe cognitive impairment fell without a root cause analysis or new interventions. Another resident with brain cancer and seizures had multiple falls without documented interventions or analysis. A third resident with dementia fell due to a slippery fall mat, with no documented interventions or analysis.
The facility failed to report allegations of abuse and neglect involving three residents. One resident's sexual abuse allegation was not reported to law enforcement, while another's report of rough handling by a CNA was not communicated to the State Agency or law enforcement. Additionally, a resident left unsupervised in the tub was not reported as neglect. Interviews with the Social Service Director and Director of Nursing confirmed these incidents should have been reported.
The facility failed to investigate allegations of abuse and neglect involving two residents. One resident reported rough handling by a CNA, and another reported inattentive supervision during bathing, posing a risk of slipping. Despite these reports, the facility did not conduct necessary investigations or interviews with staff and residents, as acknowledged by the SSD and DON.
Unauthorized Access to Narcotic Keys by Medication Aides
Penalty
Summary
The facility failed to ensure that only authorized staff had access to the keys for the locked narcotic box and medication storage room. Observations showed that two Certified Medication Aides (CMAs) were in possession of the keys to the medication cart and the locked narcotic box, despite facility policy and their job descriptions explicitly stating that CMAs are not permitted to pass or access narcotic medications. Both CMAs confirmed during interviews that they held the keys during their shifts and participated in verifying narcotic counts with the narcotic binder, although they stated they did not administer narcotics to residents. Interviews with nursing staff, including an LPN and an RN, confirmed that only nurses are allowed to dispense narcotic medications. Review of facility policies indicated that the responsibility for the keys to Schedule II medication storage areas lies solely with nurses, and access to these keys should be limited to those who require them. The Administrator and Director of Nursing acknowledged that the CMAs should not have had access to the narcotic box keys, confirming this was contrary to facility policy. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency as required by facility policy and state law. Specifically, staff documented two resident-to-resident altercations involving two residents, but these incidents were not reported to the State Agency, and one was not reported to the administrator. The facility's abuse prohibition policy requires immediate reporting of such allegations, but this procedure was not followed in these cases. Documentation showed that after supper, one resident exhibited aggressive behaviors, including yelling at another resident and throwing an object in their direction. The same resident also threatened another by slamming her walker into a chair and making a verbal threat. The LPN who documented the events reported only one of the incidents to the administrator and was uncertain about reporting the other. During interviews, both the LPN and the administrator acknowledged that these events should have been reported as allegations of abuse to both the administrator and the State Agency, but this did not occur.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for two of five residents reviewed. Staff documented observations of resident-to-resident altercations involving two residents on the same date, but there was no indication that these incidents were investigated by the facility as required by their abuse prohibition policy. The policy mandates immediate investigation when there is suspicion or report of abuse, neglect, or exploitation. Surveyors reviewed a progress note authored by an LPN, which described an incident where one resident yelled profanities at another, threw a wander guard in the direction of a resident, and later slammed a walker into a chair while making a threatening statement to a different resident. During an interview, the Nursing Home Administrator confirmed that these events should have been investigated as allegations of abuse, but no investigation was conducted.
Deficiency in Pressure Ulcer Care for a Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, leading to a deficiency in care. The resident, who was admitted with a stage 2 pressure injury on her left elbow and had a high risk for pressure ulcer development, did not receive appropriate interventions to manage and heal her pressure injuries. The facility's policy required a care plan with measurable goals and interventions, but these were not effectively implemented or communicated to the staff. The resident's care plan included interventions such as evaluating skin for redness, monitoring ulcer characteristics, and providing wound care per treatment order. However, the facility did not transcribe or carry out orders effectively, and there was no guidance for CNAs on managing the resident's pressure injuries. The resident's nutritional orders included protein supplements for wound healing, but there was no documentation of consistent application of these interventions. Additionally, the facility did not provide a specialty pressure-relieving mattress or any pressure-relieving devices, and the resident's foot was observed directly on the mattress during treatment. The facility's failure to implement and document necessary interventions resulted in the resident's pressure injury worsening, with signs of infection and tunneling. The facility did not document the application of border foam dressing or the Santyl treatment consistently, and there was a lack of communication and coordination among staff regarding the resident's care. The deficiency was further compounded by an environmental emergency that required the transfer of residents to other facilities, during which time the resident's treatments were not documented. The facility's inaction and lack of proper documentation and communication led to the deficiency in pressure ulcer care.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was in pain and discomfort during care provided by CNA D. Despite the resident's repeated requests to stop, CNA D continued with the care, causing the resident to scream in pain. Other staff members, including CNAs and an LPN, were present and overheard the resident's distress but did not intervene to stop the abuse. The resident, who had been admitted to the facility with serious medical conditions including a malignant neoplasm and nontraumatic intracranial hemorrhage, was under hospice care at the time of the incident. The resident had expressed a preference for a male caregiver and had refused care from female staff members, including the administration of medications and changes to his brief. Despite this, CNA D proceeded with the care against the resident's wishes, using dismissive language and ignoring the resident's cries of pain. Interviews with other residents revealed that CNA D had a history of disregarding residents' wishes and making them feel unsafe. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the lack of intervention from other staff members and the failure to educate all staff on abuse prevention following the incident. The facility's response to the incident, including the timing of the report to the state agency, was also inadequate.
Removal Plan
- Care Plan for R40 updated to address pain management: Breathing, Stress Balls during Care, Medications for Pain scheduled instead of PRN
- Discussion between CNA D and Interim NHA A related to resident rights and customer service
- Inservice for all staff on Resident rights/self-determination
- Continue touch bases with R40 to determine if needs are being met
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all 39 residents. During an inspection, several deficiencies were observed in the kitchen's dry storage and main refrigerator. Unopened pasta bags and canned goods lacked use-by dates, while a container of sunflower seeds was past its use-by date. Additionally, thawed nutritional supplements had no thaw dates, contrary to manufacturer guidelines. Furthermore, a staff member entered the kitchen without a hairnet, and a scoop was improperly stored inside a sugar container, raising concerns about cross-contamination and infection control.
Lack of QAPI System and PIPs in Facility
Penalty
Summary
The facility failed to establish and maintain a Quality Assurance and Performance Improvement (QAPI) system, which is necessary for identifying and addressing quality deficiencies. The facility's policy, dated 1/1/24, mandates the development and implementation of a comprehensive, data-driven QAPI program that focuses on care outcomes and quality of life. However, upon review, there was no evidence of a Performance Improvement Project (PIP) in place to enhance the quality of care for the residents. This deficiency has the potential to affect all 39 residents in the facility. During an interview, the Nursing Home Administrator (NHA) admitted to having conducted only one QAPI meeting since assuming the role in October and acknowledged that the facility was not currently working on any PIPs. The NHA recognized the necessity of having at least one PIP annually to ensure quality care but cited leadership changes as a barrier to prioritizing the QAPI plan and initiatives. The lack of a structured QAPI process and the absence of ongoing PIPs indicate a failure to follow the facility's QAPI plan, which is crucial for identifying and addressing problem areas to ensure resident care quality.
Deficiency in QAA Committee Composition and Meeting Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required members and did not meet the quarterly meeting requirements. The QAA Committee was supposed to include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members including the Administrator, Owner, or a Board Member, and the Infection Preventionist (IP). However, the review of the QAPI Committee meeting sign-in sheets revealed that the IP was absent from all meetings in the past year, and the Administrator was absent from one meeting. During an interview, the Nursing Home Administrator (NHA) was unaware that the IP needed to attend the QAPI meetings, as infection control topics were presented by the Director of Nursing (DON). The facility's policy, however, clearly stated the requirement for the IP's attendance. This oversight in the composition of the QAA Committee has the potential to affect all 39 residents residing within the facility.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by several deficiencies identified during the survey. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal, which posed a potential infection control issue. The Nursing Home Administrator (NHA) acknowledged the situation and agreed that residents should have been seated elsewhere to avoid exposure to the dripping water. Additionally, the facility lacked a mechanism for tracking Multi-Drug Resistant Organisms (MDROs). Although the NHA and the Infection Preventionist (IP) were aware of which residents had MDROs, they did not have a formal tracking system accessible to others. Furthermore, the facility's monthly infection control rates were not segregated by specific infection types, making it difficult to identify trends or increases in certain infections. The NHA admitted that without segregated rates, they could not ascertain increases in specific infection types. The facility also failed to provide evidence of a comprehensive water management program. The surveyor was unable to locate descriptions of the building water system, identification of areas where Legionella and other pathogens could grow, or descriptions of control measures and monitoring processes. The NHA acknowledged that these elements should have been included in the water management program and indicated that they would check with maintenance to locate the necessary documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed in two medication carts and two medication storage rooms. On the 2nd floor, an undated open insulin pen for a resident and expired morphine tablets for another resident were found. The 3rd floor medication cart contained a cough syrup with no open or expiration date. Additionally, both the 2nd and 3rd floor medication storage rooms contained expired stock medications, such as Thiamin Vitamin B1, Super View Healthy Eyes vitamins, Paxlovid, and acetaminophen suppositories. Interviews with staff revealed inconsistencies in the understanding of medication expiration and labeling protocols. LPN I indicated that medications were considered good for 30 days after opening, while RN H stated they were good for 28 days. The Director of Nursing acknowledged that insulin pens should be dated upon first use, and the Nursing Home Administrator confirmed that nurses were responsible for checking expiration dates, with the pharmacy conducting audits every three months. However, discrepancies in labeling and storage practices were evident, leading to the observed deficiencies.
Inconsistent Weight Monitoring and Lack of Physician Notification
Penalty
Summary
The facility failed to ensure that two residents, R35 and R17, maintained acceptable parameters of nutritional status. For R35, weights were obtained using different methods, leading to unclear accuracy. The facility did not update R35's physician on weight gain or loss based on these weights. The facility's policy on weight monitoring was not consistently followed, as there was no documentation of re-weights or provider notifications for significant weight changes. Interviews with staff revealed inconsistencies in weighing methods and a lack of clear guidelines for notifying physicians about weight changes. R17 experienced a significant weight loss of 21 pounds, yet the physician was not informed, and there was no documentation of trialing supplements with R17. The facility's dietician noted changes in R17's nutritional supplements, but there was no tracking of supplement consumption or documentation of a trial of Magic Cup supplements. Interviews with the Dietary Manager and Nursing Home Administrator indicated a lack of communication and documentation regarding R17's nutritional interventions and weight changes. The facility's failure to maintain consistent weighing methods and notify physicians of significant weight changes contributed to the deficiency. The lack of documentation and communication regarding nutritional interventions and weight monitoring for both residents highlights a systemic issue in the facility's approach to managing residents' nutritional status. The interim Nursing Home Administrator acknowledged the discrepancies and the need for consistent weighing methods and documentation.
Missed Dupilumab Dose for Resident with Eczema
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R142, by not administering a scheduled dose of Dupilumab, a medication for eczema. The medication was due on 12/6/24, but it was not given, as indicated by the Medication Administration Record (MAR) which showed a circled 'M' and 'N/A' for the administration time. This omission occurred despite the physician's order dated 11/22/24, with a start date of 12/6/24. The resident's Power of Attorney for Health Care (POAHC) reported that the resident's skin condition was worsening due to the missed medication, and the facility had not provided a definitive answer regarding the issue. The facility experienced an environmental emergency, leading to the relocation of residents, including R142, to other local facilities from 11/27/24 to 12/6/24. During this period, medications were sent with the residents to the other facilities. Upon return, the facility staff did not review the MARs to identify missed medications, and the missed dose of Dupilumab was not reported to the Nursing Home Administrator (NHA). The interim NHA, who was previously the Director of Nursing, acknowledged the oversight and confirmed that the missed medication was not documented or addressed appropriately.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for two residents, R17 and R30, during a survey. R17 was administered Quetiapine, an antipsychotic medication, without appropriate diagnoses or indications for its use. The facility's documentation indicated that R17 was taking Quetiapine for depression, but there was no evidence of harmful behavior or appropriate diagnosis to justify the use of this medication. Additionally, the facility was unable to provide documentation that R17 was being monitored for agitation or aggression, which were later added as diagnoses by the physician. R30's care plan and documentation did not specify what side effects of antipsychotic, benzodiazepine, or antidepressive medications should be monitored for, nor was there any documentation indicating that R30's side effects were being monitored by staff. Interviews with various staff members, including CNAs and a Med Tech, revealed a lack of knowledge regarding the specific side effects to monitor for R30's medications. The facility's Nursing Home Administrator acknowledged that specific side effects were not listed in the Medication Administration Record and that staff relied on drug books for reference. The facility's policy on the use of psychotropic medications emphasizes the need for assessing the resident's condition, identifying underlying causes, and evaluating the effects of medications on an ongoing basis. However, the facility did not adhere to these guidelines, as evidenced by the lack of appropriate diagnoses for R17's medication use and the absence of documented monitoring for R30's medication side effects. This failure to follow policy and ensure proper documentation and monitoring contributed to the identified deficiencies.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, identified as R40, to the State Agency within the required timeframe. The incident occurred at 6:15 AM, and the facility became aware of it shortly thereafter. However, the report to the State Agency was not made until 11:14 AM, exceeding the mandated two-hour reporting window for incidents involving abuse or serious bodily injury. The facility's policy requires immediate reporting of such allegations to the administrator and relevant authorities, but this protocol was not followed in this case. R40, who was admitted to the facility with a diagnosis of malignant neoplasm of the left bronchus or lung and nontraumatic intracranial hemorrhage, was under hospice care at the time of the incident. The alleged abuse involved a CNA who continued to provide care despite the resident's request to stop due to pain. The Nursing Home Administrator acknowledged the delay in reporting to the State Agency and confirmed that the incident should have been reported within two hours, as per the facility's policy.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an accusation of physical abuse involving a resident, identified as R40, who was under hospice care and had a diagnosis of malignant neoplasm of the left bronchus or lung and nontraumatic intracranial hemorrhage. The incident involved a Certified Nursing Assistant (CNA D) who allegedly continued to provide care despite the resident's request to stop, causing the resident to report pain during the care. The facility became aware of the allegation but did not complete a thorough investigation as required by their policy. The facility's policy on abuse, neglect, and exploitation mandates an immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, interviewing all involved parties, and documenting the investigation thoroughly. However, the investigation was incomplete as it did not include all necessary steps, such as conducting skin assessments on nonverbal residents and providing staff education on abuse. The Nursing Home Administrator (NHA A) acknowledged that the investigation was not complete and should have included these additional measures. Interviews conducted by the Social Worker (SW G) revealed that several residents felt their rights were not respected by CNA D, with some expressing that they did not feel safe when CNA D was working. Despite these findings, the facility did not document all conversations with residents, and the measures taken to ensure resident safety were insufficient. The facility's failure to conduct a comprehensive investigation and adequately protect residents from potential abuse constitutes a deficiency in their care practices.
Inadequate Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents reviewed for falls. Resident R142, who has severe cognitive impairment and a history of falls, sustained a fall on 11/27/24. The facility did not conduct a root cause analysis or implement new interventions within 72 hours of the fall, as required by their policy. Observations and interviews revealed that the interventions listed in the resident's care plan were not updated following the fall, and staff were unable to locate specific fall interventions in the resident's records. Resident R16, diagnosed with malignant neoplasm of the brain and seizures, experienced multiple falls without significant injuries. Despite being at high risk for falls, the facility did not document any interventions or conduct a root cause analysis for these incidents. The care plan mentioned fall risk precautions, but these were not detailed, and there was no record of Interdisciplinary Team meetings to address the resident's continued falls. Resident R31, who has dementia, also experienced several falls, including one that resulted in a hematoma. The facility did not document any interventions or root cause analysis for these falls. Interviews revealed that the resident tripped over a fall mat, which was noted to be slippery. The facility's failure to document and analyze these incidents, as well as to implement individualized interventions, contributed to the ongoing risk of falls for these residents.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting suspected abuse, neglect, or theft in accordance with section 1150B of the Act. This deficiency was identified in three separate incidents involving residents. In the first case, a resident reported a sexual abuse allegation involving their significant other, which was communicated to the facility by Adult Protective Services (APS). However, the facility did not report this allegation to law enforcement, as required. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that both acknowledged the need to report such allegations to law enforcement, but it was not done in this instance. In the second incident, a resident reported that a Certified Nursing Assistant (CNA) was rough with her, but the facility did not report this allegation of abuse to the State Agency or law enforcement. The Social Service Director and the Director of Nursing both recognized that the incident could be considered abuse and should have been reported. In the third case, a resident reported being left unsupervised in the tub by a CNA, which was not reported as neglect to the State Agency. The Social Service Director and the Director of Nursing acknowledged that the lack of supervision could be considered neglect and should have been reported. These failures indicate a lack of adherence to the facility's policy on reporting alleged violations to the appropriate authorities.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to investigate alleged violations of abuse and neglect for two residents. For the first resident, an allegation was made on February 6, 2024, that a CNA was rough with the resident. Despite the resident being unable to identify the specific staff member involved, the facility did not conduct interviews with staff on duty at the time to narrow down the potential perpetrator. Both the Social Services Director (SSD) and the Director of Nursing (DON) acknowledged that the situation should have been investigated as a potential abuse case, and staff should have been interviewed to rule out abuse. For the second resident, an allegation of neglect was made on May 31, 2024, when the resident reported that a CNA was inattentive during bathing, leading to a potential risk of slipping. The CNA admitted to being distracted and not supervising the resident properly. The facility did not conduct an investigation into this incident, despite the acknowledgment from both the SSD and DON that the situation could be considered neglect and warranted an investigation. The failure to interview staff and other residents further contributed to the lack of a thorough investigation.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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