Lincoln Park Nursing And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Racine, Wisconsin.
- Location
- 1700 C A Becker Dr, Racine, Wisconsin 53406
- CMS Provider Number
- 525061
- Inspections on file
- 28
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lincoln Park Nursing And Rehab Llc during CMS and state inspections, most recent first.
Nursing staff failed to follow infection prevention protocols during medication administration, including placing medications and medical devices on unclean surfaces, not disinfecting shared equipment between uses, and not performing hand hygiene after glove removal. These lapses occurred while caring for multiple residents with chronic conditions such as diabetes and heart failure, and were confirmed by staff interviews and direct observation.
A resident with multiple serious health conditions did not receive two doses of their prescribed medications, carvedilol and tramadol, despite these being available in contingency stock. Instead, a dose of Eliquis, which was not ordered for the resident, was dispensed from the AMDS by an LPN. Facility policy requires medications to be administered as ordered and only prescribed medications to be dispensed, but these protocols were not followed. The DON and NHA confirmed that the physician should have been contacted for clarification, but this did not occur.
Two residents with severe cognitive impairment and behavioral issues were involved in multiple altercations, with one resident physically assaulting another on two occasions, including an incident where a wet floor sign was used as a weapon, resulting in a subdural hematoma and ICU admission. Despite known histories of aggression and wandering, staff were unable to effectively redirect or separate the residents, and care plan interventions were either delayed or ineffective, leading to a finding of Immediate Jeopardy.
The facility did not properly assess or address the behavioral and psychosocial needs of several residents with dementia and psychiatric disorders, failing to obtain critical background information from previous care settings and family, and not developing individualized care plans or interventions. This led to repeated aggressive incidents between residents, including physical altercations resulting in injury and hospitalization, and left staff unprepared to manage complex behaviors.
An allegation of one resident hitting and pinching another was not properly reported to law enforcement, despite facility records stating otherwise. No documentation or evidence was found to confirm that police were contacted, and the police department reported no calls from the facility during the relevant period.
Two residents' care plans were not updated or individualized after a resident-to-resident altercation, and interventions discussed by staff were not documented in the care plans. Additionally, there were inconsistencies between the care plans and smoking risk assessments for both residents, with conflicting information about supervision and storage of smoking materials. These deficiencies occurred despite facility policy requiring care plan updates after significant incidents.
A resident with multiple medical conditions and cognitive intactness refused showers for an extended period due to the shower room being too cold, a concern communicated to staff but not addressed with reasonable accommodations. Staff and maintenance were aware of the issue, but no interventions were implemented to help the resident stay warm during showers, resulting in the resident receiving only one bed bath in 30 days.
A resident with multiple medical conditions and cognitive intactness reported to two LPNs that staff were being rough with him during care, particularly due to knee pain. Despite facility policy requiring immediate reporting of such allegations, neither LPN reported the concern to the DON or Administrator, and the incident was not communicated to the state agency. The DON and Administrator confirmed they were unaware of the complaint, resulting in a failure to investigate or report the alleged mistreatment.
The facility did not investigate or thoroughly investigate in a timely manner two separate incidents: a resident's repeated complaints of staff being rough during care were not reported or investigated by LPNs, and a resident-to-resident altercation resulting in injury lacked a comprehensive investigation, witness statements, and care plan updates, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not have tubigrips applied as ordered in the care plan and physician orders, despite documentation indicating otherwise. Surveyors observed the resident without tubigrips on several occasions, and staff confirmed the expectation to follow the care plan, resulting in a deficiency for not providing care according to orders.
A resident with a right hand contracture and hemiplegia was not consistently provided with the recommended hand splint to maintain range of motion, despite occupational therapy and medical recommendations. The care plan did not include current interventions for splint use, and staff failed to document or address refusals or assist the resident with splint application, resulting in the resident being repeatedly observed without the splint.
A resident with an ostomy did not receive the correct supplies or care as ordered, resulting in the use of paper towels and washcloths in place of proper ostomy equipment. Staff interviews revealed confusion about supply ordering and a lack of stock, while observations confirmed the resident experienced leakage and discomfort due to inadequate supplies.
A registered nurse was observed dispensing medications to a resident by touching pills with bare hands, contrary to facility infection control policy requiring hand hygiene and glove use during medication administration. The administrator confirmed this was not proper medication handling.
The facility did not have a qualified Director of Food and Nutrition Services for its 83 residents. The Dietary Manager (DM) lacked education in food services and was unaware of the certification requirement. The DM, in the role for about a year, was preparing to take the Managerial ServSafe certification exam. The Administrator was unsure of the DM's certification status but confirmed the DM's upcoming exam.
The facility failed to provide written transfer notices to four residents and/or their POAs, relying instead on verbal communication. This deficiency was identified through record reviews and interviews, revealing a lack of compliance with the facility's Transfer and Discharge Guideline policy.
The facility failed to provide written bed hold notices to residents or their representatives upon hospital transfer, as required by policy. Four residents were transferred without receiving the necessary documentation, leading to potential confusion. Interviews confirmed that only verbal notices were given, and the DON was unfamiliar with the regulations.
The facility failed to serve food at a palatable temperature, affecting several residents. Observations showed significant temperature drops from preparation to service, with residents reporting cold and unappetizing meals. An LPN confirmed the food was difficult to chew and bland. The Dietary Manager was unaware of current issues, despite past concerns, and the DON expected better quality, indicating a lapse in adherence to food handling policies.
A resident was found with medications at their bedside without an assessment for self-administration. The resident, who was cognitively intact, had Fluticasone and saline nasal spray, and generic Sudafed pills, but no physician orders or care plan documentation for self-administration. The facility's policy requires an evaluation by a licensed nurse, which was not conducted, leading to the deficiency.
The facility failed to properly reconcile, transcribe, and administer medications for three residents, leading to potential adverse health outcomes. One resident's new medication orders were delayed, another's antidepressant was omitted from the MAR, and a third received an incorrect aspirin dose and missed insulin. These incidents highlight failures in medication administration and reconciliation processes.
A resident with a surgical amputation did not receive ordered wound care on two consecutive days, as documented in the TAR. The WCRN provided care during weekdays, while nursing staff were responsible on weekends. The resident reportedly refused care if not provided by preferred nurses, but staff failed to document refusals or reapproach the resident, leading to a deficiency in care.
The facility failed to follow physician orders for oxygen and CPAP treatment for two residents. One resident received oxygen at 5 LPM instead of the ordered 3 LPM, and another resident used a CPAP without a current physician's order. Staff confirmed these discrepancies, highlighting a lack of adherence to prescribed treatments.
A facility failed to ensure ongoing pre- and post-dialysis communication for a resident with end-stage renal disease receiving dialysis three times a week. Despite the care plan and physician orders, there were no completed communication forms in the resident's records. Staff interviews revealed a lack of established communication processes with the dialysis center, contrary to the facility's policy requiring written communication forms.
A long-term care facility failed to administer medications as ordered for four residents, leading to missed doses and delays. One resident with anemia did not receive a retacrit injection on time due to a lack of lab result confirmation. Another resident with rheumatoid arthritis missed adalimumab doses due to refill process issues. A third resident did not receive glucosamine-chondroitin due to order confusion. Lastly, a resident experienced delays in receiving carbidopa-levodopa due to insurance and communication issues.
The facility failed to maintain a medication error rate below five percent, resulting in a 12.9 percent error rate. Two residents were affected: one did not receive glucosamine-chondroitin due to a missing dose specification, and another did not receive carbidopa-levodopa due to insurance and delivery issues. The facility used an immediate release form as a temporary substitution.
The facility failed to secure a medication cart on Unit 3 Hall, leaving it unlocked and unattended, which was acknowledged by an LPN. Additionally, a resident's medications were left unsecured at the bedside while the resident was asleep, contrary to facility policy. The DON confirmed these actions were against basic nursing expectations and facility policies.
A facility failed to follow infection prevention standards during a medication pass, as an RN did not disinfect a shared glucometer between two residents with diabetes. The RN also neglected hand hygiene protocols and had personal food items on the medication cart, contrary to facility policy. The DON confirmed these lapses in procedure.
A resident with severe cognitive impairment was injured by another resident after a wheelchair incident. The facility failed to update the care plan for the aggressive resident, despite the incident being reported and witnessed by staff.
The facility failed to report an allegation of resident-to-resident abuse to the state agency. A resident with moderately impaired cognition reported being slapped by another resident with intact cognition. The incident was not documented in the electronic medical records or incident report. The facility's decision not to report was based on an algorithm indicating no harm, despite the resident's consistent story and the facility's policy requiring reporting within two hours if abuse was involved.
The facility failed to update care plans for a resident with aggressive behavior, another with alcohol use and disruptive behaviors, and a third with a change from a Foley to a suprapubic catheter. Despite incidents and changes in condition, care plans lacked necessary interventions and updates, as confirmed by staff interviews and policy reviews.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
Surveyors observed that nursing staff failed to maintain proper infection prevention practices during medication administration for six residents. Specifically, two nurses were seen placing medications and medical devices, such as glucometers and insulin pens, on unclean surfaces without disinfecting them before or after use. Shared equipment, including blood pressure cuffs and pulse oximeters, was not cleaned between residents, and personal protective equipment (PPE) was not appropriately donned or doffed between resident care activities. In several instances, hand hygiene was not performed after glove removal, and items were returned to the medication cart without proper disinfection or adherence to required contact times for germicidal wipes. The residents involved had significant medical conditions, including diabetes, heart failure, and asthma, which required frequent monitoring and medication administration. During medication passes, nurses were observed placing glucometers and insulin pens on bare surfaces of medication carts and bedside tables, both in common areas and resident rooms. In multiple cases, nurses failed to sanitize equipment between uses and did not follow hand hygiene protocols after removing gloves or before handling medications and devices for different residents. These actions were confirmed by staff interviews, where nurses acknowledged not following established infection control protocols due to being rushed or distracted by other duties. Facility policies and CDC guidelines reviewed by surveyors clearly required cleaning and disinfecting shared equipment before and after each use, performing hand hygiene according to established procedures, and using PPE appropriately. The Director of Nursing confirmed that staff were expected to adhere to these protocols. However, direct observations and staff admissions demonstrated that these standards were not consistently followed during the observed medication administration processes.
Failure to Administer Ordered Medications and Unordered Medication Dispensed
Penalty
Summary
A deficiency occurred when a resident did not receive two doses of their ordered medications, carvedilol and tramadol, as documented in the Medication Administration Record (MAR) for a specific morning. The nurse's note indicated that these medications were not administered due to awaiting pharmacy delivery, despite the facility having both medications available in contingency stock. The carvedilol available was of a lower dose, but two tablets could have been given to achieve the prescribed dosage, and the physician was not contacted for clarification. Additionally, the facility's Automated Medication Dispensing System (AMDS) records showed that Eliquis, a medication not prescribed for the resident, was dispensed to them by an LPN, who later did not recall this action. The resident had multiple diagnoses, including a right fibula fracture, cardiomyopathy, heart failure, and kidney failure. The facility's policies require medications to be administered according to physician orders and that only prescribed medications be removed from the AMDS. The surveyor found that the resident's prescribed aspirin had a major interaction with Eliquis, and three other medications had moderate interactions, according to a drug interaction checker. The facility's leadership acknowledged that the physician should have been contacted regarding the medication issue, but this was not done.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in multiple incidents of resident-to-resident altercations. One resident, with a history of severe cognitive impairment, Alzheimer's Disease, and substance abuse, was physically assaulted on two separate occasions by another resident known for physical aggression, severe cognitive impairment, and behavioral disturbances. The first incident involved the aggressive resident striking the other resident in the arm twice in a common area, despite staff attempts to redirect both individuals. The second incident escalated when the same aggressive resident struck the other in the back and later in the head with a wet floor sign, causing a subdural hematoma and necessitating an ICU stay. The facility's records indicate that both residents had documented histories of behavioral issues, including wandering, aggression, and refusal of care or medications. Care plans for both residents included interventions such as redirection, monitoring, and providing calm environments, but these were either initiated after the incidents or were not effective in preventing the altercations. Staff statements and facility self-reports confirm that both residents were known to wander and become agitated, and that staff were unable to successfully redirect or separate them before the physical altercations occurred. Additionally, the aggressive resident had a pattern of refusing prescribed psychotropic and other medications, which was known to the facility and documented in the medical record. The facility's policy required immediate investigation and protective measures in cases of abuse, as well as ongoing assessment and care planning for residents with behaviors that might lead to conflict. However, the facility did not prevent the repeated physical abuse, nor did it implement effective interventions to separate or supervise the residents in a manner that would have prevented further harm. The failure to protect residents from abuse resulted in significant injury and constituted a finding of Immediate Jeopardy.
Failure to Provide Medically-Related Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide medically-related social services to help residents achieve the highest practicable physical, mental, and psychosocial well-being, as evidenced by the lack of proper assessment, care planning, and intervention for four residents with significant behavioral and psychosocial needs. For two residents with severe cognitive impairment and behavioral disturbances, the facility did not obtain or utilize pertinent information from previous care settings, family, or hospice providers prior to admission. This resulted in the absence of individualized psychosocial interventions and inadequate care plans to address their complex behaviors, including aggression, wandering, and refusal of care. The facility also did not assess or address the trauma backgrounds or social histories of these residents, which were relevant to their care and management. The report details that one resident with Alzheimer's disease, alcohol abuse, and PTSD exhibited aggressive and wandering behaviors upon admission. The facility did not reach out to the resident's previous assisted living facility, hospice, or activated power of attorney to gather essential background information and effective behavioral interventions. As a result, staff were unprepared to manage the resident's behaviors, which included physical and verbal aggression, wandering into other residents' rooms, and rejection of care. Care plans and interventions were either delayed or implemented after the resident was hospitalized following an altercation with another resident. Another resident with psychosis, vascular dementia, and major depressive disorder also demonstrated increasing aggressive behaviors and medication refusals after admission. The facility did not assess these behaviors or develop appropriate psychosocial interventions based on observed patterns. The resident's refusal to take prescribed medications, which were critical for managing dementia and behavioral symptoms, was not adequately addressed in the care plan. The lack of assessment and intervention contributed to repeated altercations between residents, resulting in injury and hospitalization. Additionally, the facility did not assess or address the psychosocial needs of two other residents following multiple altercations, nor did it have a plan for managing residents with parole status or criminal backgrounds.
Failure to Document and Report Resident-to-Resident Abuse to Police
Penalty
Summary
The facility failed to ensure that an allegation of resident-to-resident abuse was properly reported to law enforcement as required. Specifically, one resident alleged that another resident hit and pinched them in the courtyard. The facility's internal report stated that the police were notified and an investigation was initiated, with both residents assessed and found to have no injuries. However, upon review, there was no documentation or evidence to support that the police were actually contacted. The facility was unable to provide a police report or any record of the call, and the Nursing Home Administrator could not locate any documentation of the notification. The local police department also confirmed that no calls for service were received from the facility during the relevant dates.
Failure to Update and Individualize Care Plans After Resident Altercation and Inconsistent Smoking Assessments
Penalty
Summary
The facility failed to update and individualize the comprehensive person-centered care plans for two residents following a resident-to-resident altercation. Despite an incident in which one resident alleged being hit by another in the courtyard, the care plans for both individuals were not revised to include new, specific interventions to prevent further abusive situations. The care plans contained previously initiated interventions, such as using separate courtyard doors, which had not been effective in preventing the altercation. Staff interviews confirmed that while verbal education and separation of the residents were implemented, these actions were not documented or reflected in the residents' care plans. Additionally, inconsistencies were found between the residents' care plans and their smoking risk assessments. For one resident, the care plan indicated the need for supervised smoking due to unsafe behaviors, but the smoking risk assessment allowed the resident to keep their own smoking materials and did not clarify the supervision requirements. The other resident's care plan required supervision and staff-secured smoking materials, yet the risk assessment indicated the resident could smoke without supervision and keep their own materials. These contradictions were not addressed or reconciled in the care plans or assessments, and no updates were made following the most recent assessments or incidents. The facility's own policies require that care plans be updated after significant changes in a resident's condition or after incidents such as altercations. However, the care plans for both residents did not reflect the interventions discussed by staff or the outcomes of the facility's investigations. The lack of timely and individualized updates to the care plans, as well as the inconsistencies between assessments and care plan interventions, contributed to the deficiency identified by the surveyors.
Failure to Accommodate Resident's Shower Preferences Due to Cold Shower Room
Penalty
Summary
A deficiency was identified when the facility failed to reasonably accommodate the needs and preferences of a resident who expressed concerns about the shower room being too cold, resulting in the resident refusing showers. The resident, who is cognitively intact and has multiple medical diagnoses including excoriation, heart failure, and dependence on supplemental oxygen, reported not having had a shower in three months due to the cold temperature of the shower room. Despite the resident's repeated communication of this concern to staff, no interventions were offered to help the resident stay warm during showers, and the only documented hygiene provided in the last 30 days was a single bed bath. Staff interviews confirmed awareness of the resident's refusals and the stated reason of being cold, but there was a lack of documented follow-up or alternative accommodations to address the resident's comfort. The care plan and electronic health record noted the resident's preferences and history of refusals, but did not include specific interventions to mitigate the temperature issue or to reapproach the resident with solutions. Documentation of refusals did not include explanations of risks and benefits or evidence of reapproaching the resident as required by the care plan. Maintenance staff and administration acknowledged being informed of the temperature concerns and noted that the shower room temperature was measured at 73.7°F, with the baseboard heater at 87°F. While the facility was considering options to improve heating, such as additional heaters or heating lamps, no immediate accommodations were implemented to address the resident's comfort during showers. The lack of timely and reasonable accommodations led to the resident not receiving showers in accordance with their needs and preferences.
Failure to Timely Report Allegation of Staff Mistreatment
Penalty
Summary
The facility failed to report an allegation of staff mistreatment involving one resident to the Nursing Home Administrator and the State survey agency within the required timeframe. The resident, who was cognitively intact and had multiple medical conditions including diabetes, hemiplegia, peripheral vascular disease, depression, atrial fibrillation, and a left below-knee amputation, voiced concerns to two LPNs about staff being rough with him during care. Both LPNs acknowledged that the resident complained of staff roughness, particularly during changes and care related to his knee pain, but neither reported the allegation to the Director of Nursing or the Administrator as required by facility policy. One LPN documented the concern in the 24-hour report but did not escalate it further. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that neither was made aware of the resident's complaints. The facility's policy requires immediate reporting of all alleged violations to the Administrator and state agency, but this process was not followed. The failure to report the allegation of mistreatment resulted in the incident not being investigated or communicated to the appropriate authorities as mandated.
Failure to Investigate Allegations of Abuse and Resident Altercation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or mistreatment were investigated or thoroughly investigated in a timely manner for two separate incidents involving three residents. In the first incident, a resident with multiple medical conditions, including diabetes, hemiplegia, and amputation, repeatedly complained to two LPNs that staff were being rough with him during care, particularly due to his knee pain. Both LPNs acknowledged hearing these complaints but did not report them to the Director of Nursing (DON) or the Nursing Home Administrator (NHA), nor did they initiate an investigation. The DON and NHA were unaware of the complaints until informed by the surveyor, and no investigation was conducted prior to the resident's discharge. In the second incident, two residents with severe cognitive impairment were involved in a resident-to-resident altercation, where one struck the other in the face, resulting in a chin abrasion and facial swelling. The facility's misconduct incident report lacked critical details, such as the names of witnesses and staff statements describing the events before, during, and after the altercation. The working schedule for the day of the incident was incomplete, making it unclear which staff were assigned to the residents involved. The care plans for the resident who initiated the altercation were not updated with new interventions following the incident, and the investigation did not include a root cause analysis or comprehensive documentation as required by facility policy. The facility's policy mandates immediate and thorough investigation of all allegations of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved parties, and providing complete documentation. In both cases, these procedures were not followed, resulting in a lack of timely and thorough investigation into the reported and observed incidents. The surveyor found that the facility did not meet its own policy standards or regulatory requirements for responding to and investigating allegations of abuse and resident-to-resident altercations.
Failure to Apply Tubigrips as Ordered for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, vascular dementia, anxiety disorder, and paranoid schizophrenia did not receive care in accordance with physician orders and the comprehensive care plan. The resident's care plan and physician orders specified that tubigrips were to be applied in the morning and removed at bedtime to address edema. The resident was assessed as severely cognitively impaired and dependent for lower body dressing, with these interventions documented in the CNA Kardex and treatment administration record (TAR). On multiple occasions throughout the day, surveyors observed the resident without tubigrips, despite documentation in the TAR indicating they had been applied as ordered. Staff interviews confirmed awareness of the care plan requirements, and the DON acknowledged the expectation that staff follow the care plan and Kardex. The deficiency was identified due to the failure to ensure the resident received the prescribed treatment and care as ordered and documented.
Failure to Ensure Consistent Use of Hand Splint for Resident with Contracture
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia and hemiparesis following a cerebral infarction, as well as other chronic conditions, was not provided with appropriate treatment and services to maintain or improve range of motion (ROM) in the right hand. The resident had a significant contracture in the right hand and was recommended by occupational therapy to wear a right hand splint during waking hours to prevent further decline in ROM. Despite these recommendations, the resident was repeatedly observed by the surveyor not wearing the splint, and the splint was seen on the resident's counter rather than in use. Review of the resident's care plan and medical records revealed inconsistencies and omissions. The current care plan did not include an intervention for the resident to wear the right hand splint, and previous interventions related to splint use had been marked as resolved without documented justification. Occupational therapy and medical assessments continued to recommend daily splint use, but these recommendations were not reflected in the active care plan or consistently implemented by staff. Additionally, the resident's Kardex did not document the need for a right hand splint, and there was no evidence of regular monitoring or documentation of splint application, resident refusals, or staff interventions as required by facility policy. Interviews with staff indicated a lack of consistent communication and documentation regarding the resident's use of the splint and any refusals. The resident stated willingness to wear the splint if assisted, but reported that staff had not offered to help with application on the day of observation. Staff confirmed awareness of the splint but did not consistently report refusals or ensure the splint was applied. Facility leadership acknowledged that refusals and interventions should be documented, but no such documentation was found during the survey.
Failure to Provide Ordered Ostomy Supplies and Care
Penalty
Summary
A resident with a history of bowel obstruction and an ostomy device did not receive ostomy care and supplies consistent with professional standards of practice. The resident was observed using paper towels and washcloths in place of proper ostomy supplies due to the facility running out of the required items. Multiple staff interviews confirmed that the facility did not maintain a stock supply of ostomy supplies, and there was confusion among staff regarding the ordering process and responsibility for ensuring adequate supply. The resident's care plan indicated a preference for self-care of the colostomy, but also documented behaviors such as resistance to care and use of non-standard materials, which led to skin irritation and incontinence. The resident's medical record included orders for a two-piece ostomy system, with instructions to provide two pouches per shift and change the wafer every seven days. However, staff interviews revealed that the resident was not provided with the correct supplies as ordered, and there was a lack of clarity about the type and quantity of supplies to be provided. Staff also reported that the resident's insurance only covered one pouch per day, and there was no clear process for requesting an increase in supply quantity. Documentation showed that the last delivery of ostomy supplies occurred about a month prior to the survey, and at the time of the survey, the resident had run out of supplies and was waiting for a new order to arrive. Observations by the surveyor confirmed that the resident experienced leakage of bowel contents onto their gown and expressed discomfort due to the lack of appropriate supplies. Staff responses to the situation were inconsistent, with some unaware of the resident's current supply status and others unsure of the correct procedure for addressing supply shortages. The facility's failure to provide the ordered ostomy supplies and maintain an adequate stock resulted in the resident not receiving care in accordance with professional standards.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse was observed dispensing medications to a resident without following proper infection control procedures. Specifically, the nurse handled each pill with bare hands, including opening over-the-counter medications and popping pills from a blister pack directly into her bare hands before placing them into a medication cup for the resident. The facility's policy requires staff to adhere to infection control practices, such as handwashing and the use of gloves, during medication administration. During an interview, the nursing home administrator confirmed that this was not the appropriate way to handle medications.
Lack of Qualified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the Director of Food and Nutrition Services for all 83 residents. The personnel record for the Dietary Manager (DM) showed no education related to food services. During an interview, the DM, who had been in the position for about a year, admitted to not being aware of the requirement for certification and stated that no one had informed her of the need for certification. She acknowledged that having certification would be beneficial and mentioned that she was scheduled to take the Managerial ServSafe certification exam soon. The Administrator, during a separate interview, was unsure about the DM's certification status but confirmed that the DM was enrolled for an examination.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notices of transfer or discharge to four residents and/or their power of attorney (POA) as required by their Transfer and Discharge Guideline policy. The policy mandates that written notice be given to residents and their representatives in a manner and language they understand. However, the facility only provided verbal notifications, which is insufficient according to the policy. Resident 331, who was admitted with multiple diagnoses including Myasthenia Gravis and dementia, was sent to the hospital after a fall. Although the POA was verbally notified, there was no written transfer notice documented. Similarly, Resident 11, with severe cognitive impairment, was transferred to the hospital after an episode of unresponsiveness, but again, only verbal notification was given to the POA, with no written documentation. Resident 57, with severe cognitive impairment, and Resident 18, with intact cognition, were both transferred to the hospital multiple times. In both cases, the facility failed to provide written notices of transfer, relying instead on verbal communication with the POAs or the residents themselves. Interviews with the Admissions Director and the Director of Nursing revealed a lack of familiarity with the regulations regarding transfer forms, contributing to the deficiency.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for four residents, each of whom was transferred to a hospital without receiving the necessary written documentation. The facility's policy, dated 04/25/19, mandates that residents or their representatives be given written information about the duration of the state bed-hold policy, the reserve bed payment policy, and the facility's policies regarding bed-hold periods before a transfer occurs. Resident 331, who was admitted with multiple diagnoses including Myasthenia Gravis and dementia, was transferred to the hospital after a fall, but only verbal consent was documented from the POA. Resident 11, with severe cognitive impairment due to conditions like Parkinson's disease and schizophrenia, was transferred after a medical episode, and again, only verbal notification was documented. Resident 57, with severe cognitive impairment and conditions such as heart failure, was transferred twice, with only verbal notifications documented for both instances. Resident 18, who had intact cognition, was transferred multiple times, and although she declined a bed hold on one occasion, she reported not receiving written notice of the policy. Interviews with the POAs and residents revealed that they did not receive any paper documentation regarding the bed hold policy, leading to potential confusion or distress. The Admissions Director confirmed that verbal notices were given, and the DON admitted unfamiliarity with the regulations concerning bed hold forms. This lack of adherence to policy could affect 83 residents, potentially causing confusion or distress regarding their return to the facility after hospitalization.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was at a palatable temperature, affecting five out of six residents reviewed for palatability. Residents reported that the food was consistently cold, lacked variety, and was not flavorful. Specific residents, including those with varying levels of cognitive impairment, expressed dissatisfaction with the temperature and quality of the meals. Observations during meal preparation confirmed that food temperatures dropped significantly from the steam line to the point of service, with rice, chicken patty, and broccoli served at temperatures well below the initial cooking temperatures. During an observation, a test tray was prepared and served, revealing that the food temperatures had decreased significantly by the time it reached the residents. An LPN who tested the tray found the chicken patty difficult to chew and the rice and broccoli cold and bland. The Dietary Manager was surprised by the findings, despite acknowledging past concerns about food temperatures. The Director of Nursing expected the food to be enjoyable and chewable, but the facility's policy on food service preparation, which was last revised in July 2014, was not effectively ensuring compliance with safe food handling practices.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R30, was assessed and evaluated for the self-administration of medications. R30, who was admitted with a diagnosis of acute respiratory failure, was found to have a BIMS score indicating cognitive intactness. During observations, it was noted that R30 had a bottle of Fluticasone and saline nasal spray on the bedside table, which the resident confirmed were their medications. However, there were no physician orders for the administration of Fluticasone nasal spray, and the resident's care plan lacked documentation regarding self-administration of medication. Further observations and interviews revealed that R30 also had generic Sudafed pills in the room, and the resident refused to let staff remove the medications, claiming ownership. The LPN and DON confirmed that an assessment for self-administration had not been conducted for R30, despite the presence of medications in the room. The facility's policy requires an interdisciplinary team to determine the safety of self-administration, and a licensed nurse must complete an evaluation to assess the resident's ability to self-administer medication. This process was not followed for R30, leading to the deficiency.
Medication Administration and Reconciliation Failures
Penalty
Summary
The facility failed to properly reconcile, transcribe, and administer medications for three residents, leading to potential adverse health outcomes. For one resident, new medication orders following a hospital discharge were not entered into the electronic medical record (EMR) or administered until four days after the resident's return, despite the Director of Nursing's expectation that new orders be entered within a few hours. This delay in administering antibiotics and steroids could have impacted the resident's recovery from acute on chronic respiratory failure. Another resident experienced a lapse in medication management when their antidepressant, sertraline, was not included in the medication administration record (MAR) upon return from the hospital. The facility's staff did not notify the nurse practitioner of the omission, which was significant given the high dose of sertraline the resident had been receiving. The nurse practitioner was unaware of the discontinuation until a follow-up visit, which hindered the planned tapering of the medication. A third resident was administered an incorrect dose of aspirin and did not receive their scheduled insulin during a morning medication pass. The registered nurse involved initially claimed to have administered all medications but later confirmed the errors upon review. These incidents highlight failures in medication administration and reconciliation processes, as well as lapses in communication among the facility's staff.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care treatments as ordered for a resident who was admitted with a primary diagnosis of aftercare following a surgical amputation. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was supposed to receive daily wound care for his left leg below-knee amputation site. However, the Treatment Administration Record (TAR) indicated that the resident did not receive wound care on two consecutive days, with the staff member marking the treatment as refused without proper documentation or a corresponding progress note. Interviews revealed that the Wound Care Registered Nurse (WCRN) provided wound care during weekdays, while the nursing staff was responsible for weekends. The WCRN noted that the resident had a habit of refusing care if not provided by preferred nurses, but emphasized the importance of documenting refusals and reapproaching the resident. The Director of Nursing (DON) confirmed that there was a lack of appropriate documentation and communication regarding the refusals, which contributed to the failure in providing care as per the physician's orders.
Failure to Follow Physician Orders for Oxygen and CPAP
Penalty
Summary
The facility failed to adhere to physician orders for oxygen administration and CPAP treatment for two residents. For one resident, the oxygen concentrator was consistently set at 5 liters per minute (LPM), contrary to the physician's order of 3 LPM. This discrepancy was observed over several days, and both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the incorrect setting. The resident's care plan did not document any non-compliance by the resident to maintain the prescribed oxygen level. For another resident, the facility administered CPAP treatment without a current physician's order. Although the resident's family member confirmed the nightly use of the CPAP, and the treatment was documented in the Treatment Administration Record, there was no physician's order for the CPAP upon the resident's readmission to the facility. The LPN and DON confirmed the absence of a current order, noting that the treatment continued based on a previous order before the resident's hospital stay.
Failure in Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure ongoing pre- and post-dialysis communication for a resident receiving dialysis three times a week. The resident, identified as R59, was readmitted with a diagnosis of end-stage renal disease and required dialysis treatment. Despite the resident's care plan and physician orders indicating the need for dialysis three times weekly, there were no completed pre- and post-dialysis communication forms in the resident's electronic medical record. Interviews with facility staff, including the Assistant Director of Nursing and a Licensed Practical Nurse, revealed that there were no established communication forms or processes in place to share vital information such as weights and vitals with the dialysis center. The Director of Nursing acknowledged that communication with the dialysis center was conducted on an as-needed basis, and there were no longer any binders for dialysis residents, although there used to be. The facility's policy on dialysis communication, which was last revised in 2007, required written communication forms to include daily weights and any changes in condition or mood. The lack of adherence to this policy and the absence of a structured communication process between the facility and the dialysis center contributed to the deficiency identified by the surveyors.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications as ordered by their physicians, affecting four residents. For one resident with anemia in chronic kidney disease, a retacrit injection was not administered on the scheduled date because the pharmacy did not receive the necessary lab results in time. The Unit Manager failed to confirm the receipt of the labs by the pharmacy, resulting in a delay in medication administration. Another resident with rheumatoid arthritis did not receive their prescribed adalimumab injections on multiple occasions. The LPN, who was an agency nurse, was unaware of the process to ensure medication refills, leading to missed doses. The Director of Nursing acknowledged a lack of communication between the facility's electronic medical records and the pharmacy, which contributed to the issue. A third resident did not receive their glucosamine-chondroitin medication due to a lack of clarity in the order and the absence of the medication in the facility. The RN administering the medication was unable to find the correct formulation and needed to clarify the order with the nurse practitioner. Lastly, a resident with a new order for carbidopa-levodopa experienced a delay in receiving the medication due to insurance issues and a lack of communication between the facility and the pharmacy. The medication was on back order, and the facility had not documented the situation adequately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12.9 percent error rate during the observation of medication administration. This deficiency affected two residents. One resident, admitted with chronic pain, did not receive her prescribed glucosamine-chondroitin due to the absence of a specified dose in the order, which led the nurse to withhold the medication. The resident confirmed she had not received the medication since admission, understanding it was an over-the-counter drug not yet available at the facility. Another resident, with diagnoses including heart failure and restless legs syndrome, did not receive her prescribed carbidopa-levodopa due to insurance issues and a delay in delivery. The medication was on hold, and although the pharmacy had sent a supply, it was not available for administration. The resident was aware of the situation and expressed concern over not receiving an oral antibiotic after a hospital visit. The facility had the immediate release form of the medication in their contingency supply, which was used as a temporary substitution.
Medication Security and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the security of medication carts and the proper administration of medications, as observed on Unit 3 Hall. A medication cart was found unlocked and unattended in the hallway, with the computer screen slightly down but not locked. This occurred while a resident in a wheelchair used the cart to pull himself past, and other staff and visitors walked by. An LPN acknowledged the cart was unlocked but did not provide further explanation. The Director of Nursing (DON) confirmed that it is a basic expectation for nurses to lock medication carts when not in view, as per the facility's policy. Additionally, the facility did not secure medications during administration for a resident, identified as R37. The resident's medical record indicated a history of acute respiratory failure and muscle weakness, with a cognitive status deemed intact. An observation revealed that medications were left on the bedside table while the resident was asleep. The LPN responsible confirmed leaving the pills at the bedside, assuming the resident had taken them. The DON acknowledged that medications should not be left unsecured and should be administered when the resident is available, as outlined in the facility's medication administration policy.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection prevention standards during a medication pass, specifically in the use and cleaning of glucometers. Observations revealed that a registered nurse (RN) did not disinfect the glucometer between uses on two residents, both of whom had diabetes and required regular blood glucose monitoring. The RN used the same glucometer on both residents without cleaning it, and failed to perform hand hygiene before and after handling the glucometer and administering medications. Additionally, personal food items were found on the medication cart, which is against facility policy. Resident 282, who had a severely impaired cognitive status, and Resident 135, who had intact cognition, were both subjected to blood glucose checks with the same uncleaned glucometer. The RN did not follow the facility's policy of using Clorox Bleach Germicidal Wipes to clean the glucometer between residents, nor did she perform hand hygiene as required by the facility's hand hygiene policy. The Director of Nursing confirmed that the facility's policy was not followed, and that personal food items should not be on the medication cart.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in an injury. Resident 25, who is severely cognitively impaired with a BIMS score of six, was involved in an incident with Resident 66, who also has severe cognitive impairment with a BIMS score of three. The incident occurred when Resident 25 accidentally rolled over Resident 66's toes with a wheelchair, prompting Resident 66 to aggressively grab and twist Resident 25's arm, causing bruising. This event was witnessed by staff, who intervened to separate the residents. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of an updated care plan for Resident 66 following the aggressive behavior. Although the incident was reported to the Administrator, state agency, and local police, the care plan for Resident 66 did not reflect any new interventions to address the aggressive behavior demonstrated during the incident. The facility's failure to update the care plan for Resident 66 represents a deficiency in ensuring resident safety and preventing abuse.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state agency involving two residents. One resident, with moderately impaired cognition, reported being slapped by another resident with intact cognition while in the smoking area. The incident was not witnessed by others, and the facility did not document the allegation in the electronic medical records or the incident report. The facility's investigation was kept in a soft file, and the decision not to report was based on an algorithm that indicated no harm was done to the resident. The Director of Nursing (DON) and the Administrator were aware of the allegation, but the facility did not report it to the state department. The DON stated that the facility's policy required reporting within two hours if the allegation involved abuse or resulted in serious bodily injury. However, the facility's algorithm did not indicate the need to report, as it concluded there was no harm. The resident's story was consistent, but the facility's decision not to report was based on the resident's statement of feeling safe and the algorithm's directive.
Failure to Update Care Plans for Aggressive Behavior, Alcohol Use, and Catheter Change
Penalty
Summary
The facility failed to update the care plan for a resident, R66, who exhibited aggressive behavior following an incident where R66 twisted another resident's arm, causing injury. Despite the incident being witnessed by staff and immediate intervention to separate the residents, the care plan for R66 was not updated to reflect this aggressive behavior. Both the Regional Nurse Consultant and the Director of Nursing confirmed that the care plan should have been updated according to the facility's policy, which requires changes in a resident's condition to be reported for assessment and care plan review. Another deficiency was identified with resident R77, who had a history of alcohol dependence and exhibited disruptive behaviors upon returning to the facility intoxicated on multiple occasions. Despite several documented incidents of intoxication and disruptive behavior, including verbal abuse and refusal of medication, R77's care plan did not include any interventions for alcohol use or related behaviors. Interviews with nursing staff and the MDS Coordinator revealed a lack of communication and oversight in updating the care plan to address these issues, despite expectations that such behaviors should be care planned. Additionally, the facility failed to update the care plan for resident R69, who underwent a procedure to replace a Foley catheter with a suprapubic urinary catheter. Although there were orders for daily care and monitoring of the suprapubic catheter site, the care plan still referenced the previous Foley catheter and did not include the new catheter care requirements. The Director of Nursing acknowledged that the care plan should have been updated to reflect the change in catheter type and care needs.
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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