Lakeland Health Care Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhorn, Wisconsin.
- Location
- 1922 Cty Rd Nn, Elkhorn, Wisconsin 53121
- CMS Provider Number
- 525625
- Inspections on file
- 20
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Lakeland Health Care Ctr during CMS and state inspections, most recent first.
A resident with dementia and a history of aggressive behaviors did not have a behavior care plan or individualized interventions developed, despite repeated incidents of agitation and physical aggression. During an episode of resistive behavior, a nurse yelled at the resident, physically restrained and shook the resident, causing the resident to feel afraid. The facility failed to notify the provider in a timely manner and did not follow its own policies for managing challenging behaviors, leading to substantiated abuse.
A resident with dementia and depression exhibited ongoing aggressive and resistive behaviors, but staff did not develop or implement a behavior care plan or consistently notify the MD as required. Despite repeated incidents of agitation and aggression, no individualized interventions were added for over three months, and staff lacked clear guidance. The situation escalated to an incident where a nurse yelled at and physically restrained the resident, resulting in the resident expressing fear of staff.
A resident with multiple medical conditions was given medications not prescribed to them by a nurse, leading to an emergency room visit. The incident was not reported to the Administrator or DON within the required timeframe, and only nursing staff had received education on abuse and neglect reporting, while other departments had not.
A resident with multiple medical conditions and intact cognition was given three medications by an RN that were not prescribed, after the RN stated to a CNA that the medications would help the resident sleep. The resident became lethargic and combative, requiring transfer to the ER for evaluation and IV fluids. The surveyor confirmed there were no physician orders for the administered medications.
A resident with dementia was left unattended on a toilet for over 3 hours by a CNA, who failed to complete the resident's care and transfer her back to bed. The resident, unable to communicate effectively, was found upset and cold by a night shift nurse. The facility confirmed the neglect, and the CNA involved no longer works there. Despite the incident, the resident showed no apparent emotional distress afterward.
The facility failed to report two abuse allegations involving multiple residents to the NHA and State Survey Agency in a timely manner. One incident involved a resident verbally abusing others, which was not reported immediately, and another involved a resident's mistreatment allegation against a CNA, delayed due to an LPN's belief of no issue. These lapses highlight deficiencies in the facility's internal reporting procedures.
Two residents experienced deficiencies in care due to the facility's failure to implement fall prevention interventions and post-fall protocols. One resident sustained a head injury that was not assessed or reported for three days, while another resident fell after being left unsupervised in the bathroom, contrary to their care plan. These incidents highlight lapses in adherence to safety protocols and individualized care plans.
Two residents were not treated with dignity during meals as a staff member stood while feeding them, contrary to facility policy. One resident, with dementia, was not given verbal cues or appropriately sized food, while another, dependent on staff for eating, did not receive the correct clothing protector. The staff member also used an undocumented nickname for one resident, further compromising dignity.
A resident with cognitive and heart conditions experienced a significant weight loss due to the facility's failure to consistently monitor their weight as per physician's orders. The resident's weight was not checked on multiple scheduled dates, leading to a 7.6-pound loss over 10 days, which was not reported to the physician until four days later. The facility acknowledged the resident's occasional refusal of care but only implemented a care plan for refusals on the day of the surveyor's exit meeting.
A facility failed to properly disinfect a resident's glucometer after use, as observed by a surveyor. An LPN used the glucometer for blood glucose testing and returned it to a plastic bag without cleaning it with a disinfectant effective against blood-borne pathogens. Interviews with staff revealed inconsistencies in disinfection procedures, with some using alcohol prep wipes, which are inadequate for this purpose. The surveyor noted the absence of appropriate disinfectant wipes on the medication cart.
Failure to Protect Resident from Physical and Verbal Abuse Due to Lack of Behavior Care Planning
Penalty
Summary
A resident with dementia, major depressive disorder, and osteoarthritis was admitted to the facility and began exhibiting aggressive and resistive behaviors within the first two weeks. Despite multiple documented incidents of physical aggression, agitation, and refusals of care over several months, the facility failed to develop or implement a behavior care plan with individualized interventions to guide staff in managing these behaviors. The resident's medical provider was not consistently notified of the increased behaviors, and there was no documentation of timely follow-up when the provider did not respond to staff communications regarding the resident's condition. On one occasion, the resident became agitated and resistive during care. A CNA attempted to calm the resident, but a registered nurse entered the room, yelled at the resident, and physically handled the resident by grabbing and throwing the resident's legs into bed, restraining the resident with a blanket, and shaking the resident's shoulders while yelling in the resident's face. The resident reported feeling afraid during this interaction. Staff interviews revealed that the nurse involved had a known history of stress-related outbursts, though not previously directed at residents. The incident was witnessed by another staff member, who intervened and reported the abuse immediately. The facility's policy required monitoring for staff burnout and the development of care plans for residents with challenging behaviors, especially those with cognitive deficits. However, the facility did not initiate a behavior care plan for the resident despite repeated aggressive incidents, nor did it ensure timely communication with the resident's provider. This lack of appropriate planning and intervention contributed to an environment where a staff member engaged in physical and verbal abuse of a vulnerable resident, resulting in a finding of immediate jeopardy.
Removal Plan
- All staff education on verbal and physical abuse.
- All staff education on resident's rights including: Freedom from mistreatment, Freedom from physical restraints, Treatment options (including the right of the resident to refuse care or treatment), Self-determinations (including the right of the resident to make decisions relating to care), and the Right of the Resident to be treated with courtesy and respect.
- All staff meeting which included additional abuse training, as well as burnout and stress management of staff. Staff not in attendance had the training available online to view.
- Audit included check-ins with residents to cover any resident concerns. Audits will continue.
- Audit included check-ins with staff to cover abuse, and staff stressors. Audits will continue.
- Grievance audit included facility staff reviewing resident grievances each weekday. Staff to audit for any area of concern related to abuse or misconduct.
- Staff interviewed other residents in the facility.
- Police were notified.
Failure to Provide Individualized Dementia Care and Timely MD Notification
Penalty
Summary
A resident with a diagnosis of dementia and major depressive disorder began exhibiting aggressive and resistive behaviors within the first two weeks of admission. Despite multiple documented incidents of physical aggression, agitation, and refusals of care over several months, the facility failed to develop or implement a behavior care plan with resident-specific interventions to guide staff in managing these behaviors. The facility also did not consistently notify the resident's medical doctor (MD) of the increased and ongoing behavioral issues, as required by facility policy. Documentation shows that staff were aware of the behaviors, but no individualized behavioral interventions were added to the care plan until more than three months after the behaviors began. Throughout the resident's stay, staff documented several episodes where the resident was physically aggressive toward CNAs, refused care, and became agitated, particularly during nighttime hours. Despite these repeated incidents, there was no evidence that the interdisciplinary team discussed these behaviors in their behavior management meetings, nor was there documentation that the MD was informed in a timely manner. When staff did attempt to notify the MD via fax about the resident's escalating behaviors, there was no follow-up when the MD did not respond over the weekend, and the issue was not addressed until days later. The lack of timely communication and absence of a comprehensive, individualized care plan left staff without clear guidance on how to manage the resident's challenging behaviors. The situation escalated when a staff member, in response to the resident's agitation and resistance, yelled at the resident, physically restrained them by holding their shoulders down and shaking them, and used a blanket to restrain the resident in bed. This incident was witnessed by another staff member, reported to management, and resulted in the resident expressing fear of staff during subsequent interviews. The facility's failure to provide appropriate treatment and services, including the development and implementation of a behavior care plan and timely communication with the MD, directly contributed to the continuation and escalation of the resident's challenging behaviors, culminating in an incident of staff-to-resident abuse.
Failure to Timely Report Potential Abuse/Neglect After Medication Error
Penalty
Summary
Facility staff failed to report an incident of potential abuse or neglect within the required timeframe after a resident received medications not prescribed to them, resulting in the resident being sent to the emergency room. The incident involved a registered nurse administering three medications—tizanidine, cyclobenzaprine, and diphenhydramine—belonging to another resident, with documentation indicating that the nurse was aware these medications were not ordered for the resident. The facility's policy requires immediate reporting of suspected abuse or neglect to the Administrator and Director of Nursing, but this was not followed, as the incident was not reported to the appropriate authorities within the mandated two-hour window. Record review and staff interviews revealed that only nursing staff received education on abuse and neglect reporting, while other departments such as food service and housekeeping had not received recent training on these requirements. The Director of Nursing confirmed that the lack of timely reporting was due to nursing staff not notifying leadership as required, and acknowledged that all staff should be included in abuse and neglect reporting education. The surveyor found no evidence of education provided to non-nursing departments regarding these reporting obligations.
Resident Administered Unprescribed Medications Resulting in Hospital Transfer
Penalty
Summary
A resident with diagnoses including heart failure, renal insufficiency, dementia, and paroxysmal atrial fibrillation was admitted with intact cognition, as indicated by a BIMS score of 13. During the night shift, a registered nurse administered three medications—Tizanidine, Cyclobenzaprine, and Diphenhydramine—that were not prescribed for the resident. Documentation from a certified nursing assistant indicated that the nurse acknowledged the resident did not have orders for these medications but stated they would help the resident sleep. The resident's medical record did not contain any physician orders for these medications. Following the administration of the unprescribed medications, the resident became increasingly lethargic, difficult to arouse, and combative with care, which was a change from their baseline. The resident was subsequently sent to the emergency department for evaluation, where laboratory tests and intravenous fluids were administered. The incident was reported to facility leadership, and the surveyor confirmed that the medications given were not ordered for the resident. No additional information was provided regarding the administration of these medications.
Resident Left Unattended on Toilet for Extended Period
Penalty
Summary
The deficiency involved a resident, identified as R61, who was left unattended on a toilet for an extended period of time, approximately 3 hours and 15 minutes, by a certified nursing assistant (CNA) during the second shift. R61, who has a diagnosis of dementia and is unable to make her needs known, required extensive assistance for toileting and was dependent on staff for transfers. On the evening of the incident, the CNA used an EZ stand to transfer R61 to the toilet but failed to complete the resident's care and transfer her back to bed before leaving at the end of the shift. The night shift nurse discovered R61 still seated on the toilet, visibly upset, and with extremities cold to the touch. Although R61 was unable to verbalize her distress, she was found saying the word "puta" repeatedly. A skin assessment revealed no immediate skin integrity issues, but bruises on the calves were noted later. The facility's investigation confirmed the neglect, and the CNA involved no longer works at the facility. R61's medical history includes dementia, major depressive disorder, muscle weakness, and anxiety, with severe cognitive impairments affecting daily decision-making. The resident's care plan explicitly stated not to leave her unattended in the bathroom, highlighting a clear breach of protocol. Despite the incident, subsequent monitoring showed no apparent emotional distress or changes in mood or behavior, and the resident was reported to be settled and pleasant following the event.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report two allegations of abuse involving five residents to the Nursing Home Administrator (NHA) and the State Survey Agency in a timely manner. The first incident involved a resident, R32, who was documented by RN-Q as verbally abusing other residents, R12, R62, and R27, on multiple occasions. These incidents were not reported immediately to the NHA as required by the facility's policy. The abuse was only discovered during a review of medical records by the facility, indicating a lapse in the internal reporting process. The second incident involved a resident, R39, who reported an allegation of mistreatment by a CNA. This allegation was not reported to the NHA until several days later, despite the facility's policy requiring immediate reporting. The delay in reporting was due to LPN-H's belief that there was no issue, as R39 appeared fine after discussing the situation. However, the facility's investigation later confirmed that the alleged CNA had worked with R39 on the date of the incident, contradicting LPN-H's initial assessment. Both incidents highlight a failure in the facility's internal reporting procedures, as staff did not adhere to the established policy of immediate reporting of abuse allegations. This failure to report in a timely manner is a significant deficiency, as it potentially compromised the safety and well-being of the residents involved.
Failure to Implement Fall Prevention and Post-Fall Protocols
Penalty
Summary
The facility failed to implement fall prevention interventions and did not consult with a physician post-fall for two residents, leading to deficiencies in care. One resident, identified as R72, sustained an injury of unknown origin to their scalp, which was not properly assessed or reported to a physician until three days later. Despite the resident reporting to a CNA that they had bumped their head on a cabinet, the LPN did not conduct a visual examination or initiate neurological checks. The facility's protocol for head injuries, which includes conducting neurological checks every shift for three days, was not followed. Another resident, R32, experienced an unwitnessed fall from the toilet due to being left unsupervised in the bathroom, contrary to their comprehensive care plan, which specifies that they should not be left alone on the toilet. R32 has a history of Alzheimer's Disease, dementia, and repeated falls, and requires substantial assistance for mobility and transfers. Despite these needs, the resident was left unattended, leading to a fall when they attempted to self-transfer from the toilet to their wheelchair. The facility's failure to adhere to established care plans and protocols for fall prevention and post-fall assessment resulted in these incidents. The lack of immediate assessment and monitoring for R72's head injury and the failure to supervise R32 in the bathroom as per their care plan highlight significant lapses in the facility's adherence to safety protocols and individualized care plans.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during meal times, as observed by the surveyor. Two residents, identified as R30 and R55, were fed breakfast simultaneously by a Recreation Therapy Leader (RTL-E) who was standing throughout the meal. This action was contrary to the facility's policy, which requires staff to be seated while assisting residents with meals to promote a dignified dining experience. Additionally, RTL-E referred to R30 by a nickname not documented in the care plan, further compromising the resident's dignity. R30, who has a history of vascular dementia, Alzheimer's disease, and other conditions, requires partial assistance with meals. The care plan for R30 specifies the use of a lipped plate with a Dycem and encourages the resident to eat slowly with verbal cues. However, RTL-E did not follow these instructions, as R30 was not informed of the food placement using clock descriptors, and the Dycem was missing. Furthermore, RTL-E fed R30 large pieces of bacon, contrary to the care plan's directive to cut food into bite-sized pieces. R55, diagnosed with Alzheimer's disease and other conditions, is dependent on staff for eating and requires a mechanically altered diet. During the observation, RTL-E did not use the appropriate clothing protector as specified in R55's care plan. Instead, a cloth napkin was used, and RTL-E continued to stand while feeding R55, which is against the facility's policy. The surveyor noted that the residents were not required to be six feet apart, contradicting RTL-E's justification for standing. These actions demonstrate a failure to adhere to the residents' care plans and the facility's policies, resulting in a deficiency in maintaining the residents' dignity during meals.
Failure to Monitor Resident's Weight Consistently
Penalty
Summary
The facility failed to provide adequate nutritional support to a resident, identified as R72, by not consistently monitoring their weight as per physician's orders. R72, who was admitted with diagnoses including cognitive communication deficit, congestive heart failure, and intracerebral hemorrhage, had a physician's order to have their weight monitored twice weekly. However, there were multiple instances of missing weight documentation on scheduled bath dates, which were the designated times for weight checks. This inconsistency in monitoring led to a significant weight loss of 7.6 pounds over a 10-day period, which was not reported to the physician until four days after the weight loss was noted. The surveyor's investigation revealed that the facility's CNAs were responsible for obtaining weights and reporting them to the unit nurse for documentation. The dietician confirmed that significant weight changes, such as the 7.6-pound loss, should be reported to the physician. During an interview, the Nursing Home Administrator acknowledged that R72 occasionally refused care, but a comprehensive care plan addressing these refusals was only implemented on the day of the surveyor's exit meeting. The delay in notifying the physician of the weight loss and the lack of consistent weight monitoring contributed to the deficiency identified by the surveyor.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to ensure proper cleaning and disinfecting of a resident's glucometer after each use, as observed by a surveyor. During a medication administration task, an LPN was seen using a glucometer to check a resident's blood glucose level without cleaning it afterward. The LPN placed the glucometer directly on the medication cart and then back into a plastic bag without using a disinfectant wipe that kills blood-borne pathogens. The LPN mentioned that the night shift nurses were responsible for cleaning the glucometers daily, using alcohol prep wipes containing 70% isopropyl alcohol, which are not effective against blood-borne pathogens. Interviews with facility staff, including a CMA and the DON, revealed inconsistencies in the facility's procedures for disinfecting glucometers. The CMA described a process involving alcohol prep wipes, while the DON mentioned using alcohol-based wipes or purple top sani-wipes after each use. The surveyor noted the absence of disinfectant bleach wipes on the medication cart and expressed concern about the use of alcohol-based wipes, which are inadequate for disinfecting against blood-borne pathogens. The facility did not provide additional information to address these concerns.
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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